FastTrack New-Change ID Form by 6Z55qV54

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									              Create New or Change FastTrack Login ID
                      GO-PKI Digital Identity Request (v2006-10b)



      This registration form is for staff requiring access to FastTrack. Staff members are
       required to meet face-to-face with to their LRA (Local Registration Authority) to present
       their original identity documents.

      You may fill out the form in paper format or within Microsoft Word. In Word, use the tab
       key or mouse to move from field to field in the "forms" fields below.


              Complete non-shaded sections 1 through 5 only.

      All FastTrack forms and detailed instructions are available on the Internet at

               http://www.fasttrack.mcys.gov.on.ca/


Printing Tip: To avoid printing this instruction page you can enter the Pages to print as “s2” in the
              Page Range section within the print window of Microsoft Word. (This document is
              divided into two sections.)




To ensure authenticity, only ORIGINAL copies of the completed and signed form are
accepted.

Please mail or send by courier to:


FastTrack Support
Ministry of Children and Youth Services
Children, Youth and Social Services I&IT Cluster
5255 Yonge Street, 5th floor
North York, ON. M2N 6P4



                           * * Do NOT email or fax this form! * *

          * * Do not attach photocopies of identification documents. * *
                                                                                                                                     MEDIUM SENSITIVITY

                                                                        GO-PKI Digital Identity Request
                                                                                                                                 (ABC Subscriber)
For issuance, agency move, or legal name change of a GO-PKI Digital Identity to Subscribers who are employees of one of
the Ontario Government’s Agencies, Boards, or Commissions.
Section 1: Subscriber Details (agency applicant)
Type of Request:              a) New (First time application)
                              b) Move from another agency                     Serial #:              Former Agency:
                              c) Name Change
                             d) Reactivate revoked ID
Prefix (Mr. Dr.):     First Name (Please print legibly):                 Middle Initls:   Last name (Please print legibly):                      Suffix (Jr. PhD):


Title:                                                                                    Full Name of Agency (“Employer“)


Work Address:                                                                             City:                               Province:          Postal Code:

(line 2)                                                                                  Work telephone #                                       Ext.


Work e-mail address (* Required Field *)
(Note – mail received at this address must be accessible only to you)

Contracting Ministry:       Ministry of Children & Youth Services


Section 2: Authorization for Issuance of Digital Identity
(to be completed by the manager for the subscriber)
I authorize the issuance of a GO-PKI Certificates to the above-named Subscriber.
I will notify the CA immediately, in the event that the Organization becomes aware of a compromise of the
certificate, or that the certificates are no longer required.
Full name:                                                                                         Work telephone #                       Ext.


Work e-mail address
(or GO-PKI serialNumber)

Approved Use of Digital Identity for the subscriber (Program/Project):
FastTrack Information System and related programs
Signature                                                                                                        Date




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                                                                                                  MEDIUM SENSITIVITY


Section 3: Acknowledgment of Subscriber - Agreement (signed by agency applicant)
The Ministry of Government Services of the Government of Ontario (‘Government of Ontario’), is issuing and
providing me (the Subscriber) with a Government of Ontario Public Key Infrastructure (GO-PKI) Digital Identity,
consisting of encryption and digital signature keys and the associated public key certificates, to identify me
digitally and enable me to securely utilize various Government services protected with GO-PKI. I understand that I
am required to use my GO-PKI Digital Identity in accordance with the Subscriber Responsibilities as set out
below. I understand that failure to adhere to the following GO-PKI Subscriber Responsibilities will result in
revocation of privileges granted through this Subscriber registration.
GO-PKI Subscriber Responsibilities
    1. The information I have submitted to the Local Registration Authority (LRA) in connection with my GO-PKI
       Digital Identity is valid, complete, and accurate.
    2. I will activate my GO-PKI Digital Identity within two (2) working days of receiving notice to do so.
    3. I will protect my GO-PKI Digital Identity and I will take all reasonable measures to prevent its modification,
       and/or use by any other person.
    4. I will take all reasonable measures to protect any and all devices containing my GO-PKI Digital Identity
       from loss and unauthorized use.
    5. I will use my GO-PKI Digital Identity only with approved applications and for government business
       purposes.
    6. I will protect my passwords, and any other information, e.g. secret questions and answers, used to
       access my GO-PKI Digital Identity.
    7. I will notify the Agency LRA immediately if there is a possibility that my GO-PKI Digital Identity has or may
       have been compromised in any way.
    8. I will notify the Agency LRA within 48 hours of a change to any information contained in my Subscriber’s
       Digital Identity Request form.


GO-PKI Notice of Collection
In accordance with the Government of Ontario-Public Key Infrastructure ("GO-PKI") Certificate Policy, the
personal information you provide on this form is collected for the purpose of issuing you a Digital Identity and
authorizing you as a GO-PKI Subscriber. The information will be used to verify your identity and ensure that the
Digital Identity you are issued correctly identifies you and no one else. The completed form will be transmitted to
The Ministry of Government Services, the ministry responsible for the implementation and management of GO-
PKI. The personal information on the form will neither be used nor disclosed for any other purpose, and will be
retained by MGS for 7 years.
The GO-PKI Certificate Policy can be obtained upon request.
I have reviewed, understand, and agree to the above.
Signature                                                                 Date


For support with your GO-PKI Digital Identity application refer to www.fasttrack.mcys.gov.on.ca




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                                                                                                                                             MEDIUM SENSITIVITY


Section 4: Authentication of Subscriber’s Identity
(to be completed by Authenticating LRA at the Children’s Aid Society)
The Subscriber must provide at least two (2) pieces of identification (originals only). If the Primary document does not contain a photograph,
then a third piece of identification is required and one of the Secondary documents must contain a photograph. Please refer to Appendix A of
the forms manual for descriptions of appropriate identification documents.

                                               Document description                                      Document number                         Expiry date
                                                                                                                                                 (if applicable)

Primary document
Note: Health & SIN cards
                                       Full name on Primary Doc.
may not be used                        (if different from Section 1)


                                                                 Secondary Document description                                                 LRA initials
                                       (Document viewed for name confirmation; DO NOT include document number)                                    (Required)

Secondary document 1

Secondary document 2                               (Required only if Primary does not contain a photo)


                                                                       A memorable date for the user:                  Hint for the memorable date:
Additional Authenticating Information
                                                                       (dd/mm/yyyy)
The Subscriber must provide three additional
pieces of information that along with the number                       A date that is memorable to the subscriber and not common knowledge. The hint is
on their Primary Document will be used to verify                       used to describe the memorable date. Do not use the user’s birthday, holidays, or
their identity remotely (eg. A phone call to a                         other dates that are common knowledge. A good example would be ‘mother’s
helpdesk).                                                             birthday’ or ‘parent’s anniversary’.

                                                                       Date Of Birth                                   Home Postal Code

                                                                       (dd/mm/yyyy)


Section 5: Authorization of Subscriber
(to be completed by the Authenticating LRA at the subscriber’s Children’s Aid Society)
I authorize the Digital Identity Request for the above named Subscriber and declare that the Subscriber’s identity has been authenticated
under the requirements set out in the GO-PKI RA/LRA Operational Procedures available upon request.

I hereby witness that the named Subscriber has read, printed his/her name into, and signed the “Acknowledgement of Subscriber” section of
this form, and was provided with a printed copy of page 1 to 3 of this Digital Identity Request form."
Full name of LRA:

LRA email
(or GO-PKI serialNumber )

Signature                                                                                                   Date




Section 6: CA Transaction
(to be completed by ministry operational LRA completing the transaction)
Certificate serialNumber (acted on):                                                   LRA email (or GO-PKI serialNumber or GoEmployeeID):



I have completed this request for the Subscriber, as set out in the GO-PKI RA/LRA Operational Procedures, on the date
below.
Signature                                                                                                   Date




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