Component Holder Document

Appendix V – Key Access Component Holder Document

I am:

CA Organization Shareholder’s Name:

_______________________________________________________________________
CA Owner Organization Name:

___________________________________________________________
CA Owner Organization’s Address:

___________________________________________________________
CA Owner Organization’s Telephone Number:

___________________________________________________________

Passport:
ID Card:
Other (specify___________)
No:____________________

I confirm that I am in receipt of the following Component(s):

Description Details:

_________________________________________________________________________

_________________________________________________________________________


I confirm that:

I have understand that I am an official Component Receipt Shareholder.

I must keep my Component information secret.

I will only reveal my Component information at scheduled Key Ceremony events.

Under penalties of perjury, I declare to the best of my knowledge and belief, that the information I have provided is true, correct, and complete.

Signature: ___________________________________ Date: ____________________


I attest that:

I have validated the identity of this Key Access Component Holder

Under penalties of perjury, I declare to the best of my knowledge and belief, that the information I have provided is true, correct, and complete.

Notary Signature: _____________________________ Date:____________________