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     SAMPLE APPLICATION FORM FOR USER CERTIFICATE

Please fill the form and send it to the PRAGMA-UCSD CA Registration
Authority (pragma-ucsd-ca at sdsc.edu).

Be sure that the name should be used as Common Name (CN) as your user
subject.

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1. Purpose of this application (new or renew, select one)
  - new

1. Name:
Yoshio Tanaka

2. Affiliation:
National Institute of Advanced Industrial Science and Technology

3. Address:
Tsukuba Central 2, Umezono 1-1-1, Tsukuba, Ibaraki 3058568, Japan

4. Phone Number:
+81-12-3456789

5. Fax Number:
+81-12-3456789

6. Email address:
yoshio@test.aist.go.jp

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