CAcert Assurance Programme Identity Verification Form

To the Assurer: The CAcert Assurance Programme (CAP) aims to assure the identities of Internet users through face-to-face verification of national identity documents. The Applicant asks you to certify to CAcert that you have met them and verified their identity against one or more original, trusted, national photo identity documents. If you have ANY doubts or concerns about the Applicant’s identity, DO NOT COMPLETE OR SIGN this form. For more information about the CAP, including detailed guides for CAcert Assurers, please visit: www.CAcert.org

CAcert Assurers
Duane Groth	Sign: ___________________	Date: ___________________
Mark Lipscombe	Sign: ___________________	Date: ___________________
__________________	Sign: ___________________	Date: ___________________ Photo ID Shown: (MUST BE GOVERNMENT ISSUED) ___________________________________________________________________ ___________________________________________________________________
Location of Face-to-face Meeting: Usenix 2005, Anaheim, CA, USA______________ Points Allocated: _______ Applicant's Statement	First Name(s):	
Last Name:	
Date of Birth: (yyyy-mm-dd)	
Email Address: (PLEASE BLOCK PRINT)	(PLEASE BLOCK PRINT)
I hereby confirm that the information stated above is both true and correct, and request the CAcert Assurer (identified below) to assert my identity in the CAP. Applicant’s signature: _______________________ Date (yyyy-mm-dd): _____________________ CAcert Inc. • P.O. Box 75 • Banksia NSW 2216 • Australia • www.cacert.org

CAcert's Root Certificate fingerprints: A6:1B:37:5E:39:0D:9C:36:54:EE:BD:20:31:46:1F:6B and 135C EC36 F49C B8E9 3B1A B270 CD80 8846 76CE 8F33

2004-06-28T03:33:28