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					                                                            SENSITIVE
HealthSecure Server
                                                                                                                             NZHSRA
Registration Form                                                                                                          Facilitated by ACC

Use this form to apply for a Digital Certificate for your Organisation’s Server

If you require assistance completing this form please contact NZHSRA (New Zealand Health & Disability
Sector Registration Authority) on 0800 117 590.

 STEP 1: ORGANISATION & SERVER DETAILS

 Organisation Name
 (as registered with
 NZHSRA)

 Phone Number              (           )


 Computer Name


                           Note: Web server URL (preferably DNS name, or IP address), or software publishing (this option must
                           include name followed by the phrase software publishing). Any address must include a registered domain
                           name or IP address owned by your organisation.

 eMail Address
 (as it should appear on
 certificates)

 Server Type                                                             PEM Format Required?                    Yes               No
 (e.g. IPSEC, SSL)

 CSR Only?                     Yes                  No               (If Yes, please include the CSR file)




 STEP 2: SERVER CONTACT’S DETAILS

 Full Name


 Job Title                                                               Work Phone Number                   (         )

 Work eMail Address



 STEP 3: SERVER CONTACT’S SECURITY

 The following information is required by HealthLink to verify your identity when:
 1) Your password is initially issued; and
 2) You need to suspend or revoke your certificate

 Date of Birth                                                           Mother’s Maiden Name


 Residential Address


 For positive identification during telephone calls and similar, we ask you for your ‘challenge phrase’. The challenge phrase is a
 unique sequence of letters and numbers with NO punctuation and a minimum of eight characters. You should keep this sequence
 in a safe place and never disclose it to anyone.

 Challenge Phrase


New Zealand Health & Disability Sector Registration Authority
In the collection, use and storage of information the NZHSRA will at all times comply with the obligations of the Privacy Act 1993 and the
Health Information Privacy Code 1994.                                                                                        PAGE 1 OF 2
                                                              SENSITIVE
                                                          SENSITIVE
 STEP 4: SERVER CONTACT’S SIGNATURE

 I have read, understood and accept the terms and conditions in HealthLink’s Certification Practice Statement, located at
 www.healthlink.net/Documentation/Digital Certificates.

 I declare that the information given in this form is true and correct, and that the NZHSRA (as the accredited Registration Authority)
 is authorised to verify this information.

 Applicant’s                                                                  Date
 Signature


 STEP 5: ORGANISATION AUTHORISED SIGNATORY

 This section must be completed by an authorised signatory in your Organisation, as supplied in your Organisation Registration with
 the NZHSRA.

 Full Name


 Job Title

 Signature                                                                    Date




 Send the original completed registration form to:
 NZH S R A
 P O BOX 30823
 LOWER HUTT




 For Office Use Only (Attach Confirmation)
 Organisation Registered                                              Administrator:

 Domain Checked                                                
 Authorised Sign Off                                                  Validator:

 Email Address Checked                                         




New Zealand Health & Disability Sector Registration Authority
In the collection, use and storage of information the NZHSRA will at all times comply with the obligations of the Privacy Act 1993 and the
Health Information Privacy Code 1994.                                                                                        PAGE 2 OF 2
                                                              SENSITIVE

				
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