CCM-02-A Form 1-1

Application for Certification (TOE)[1]

Date:

To Chairman Tatsuo Tomita

Information-technology Promotion Agency, Japan

Name of the applicant

Address

Name of the person responsible for the application

(signature)

Title/Department

The applicant hereby declares the following for submitting an application pursuant to the “Requirements for IT Security Certification (CCM-02).”

TOE name:
Version:
Name of the person in charge of the application[2] (department):
Contact information (postal code, address, telephone, e-mail):
Name of Evaluation Facility:
Name of responsible manager:
Contact information (telephone, e-mail):
Name of Developer[3]:
Name of responsible manager (department):
Contact information (postal code, address, telephone, e-mail):
An entity that providesthe evaluation deliverables other thanabove[4]:
Name:
Name of responsible manager (department):
Contact information (postal code, address, telephone, e-mail):
( ) “Name of the applicant” is described as “Name of Evaluation Sponsor.”
Evaluation criteria[5]
Evaluation methodology / ( ) CC V3.1 R5 (Japanese version), CEM V3.1R5 (Japanese version)
( ) CC V3.1 R5 (English version), CEM V3.1R5 (English version)
( ) Other ( )
( ) cPP Conformance
Name, version, and certification identification:
( ) Other than cPP Conformance
Assurance package (if applicable):
Name of existing certified PP for conformance (if applicable):
Product area[6]:
( )Software
( )Hardware (smart cards, etc.)
Purpose ofacquiring certification (select one major purpose):
Government procurement
( ) Procurement by government and local government (Procurement agency: )
( ) Procurement by overseas government (Procurement country: )
Other than government procurement
( )Private demand (Procurement entity: )
( ) Other (Purpose: )
Is there any relatedTOE[7]? / ( ) Yes
Certification number (Reception number for a product in evaluation):
TOE name:
( ) No
TOE overview (a separate sheet can be attached):
Publication of certification information[8] (select one of these options):
( ) 1 Publishing only the overview of the TOE, the name of the applicant[9]and the name of the Evaluation Facility.
( ) 2 Publishing the ST and the Certification Report in addition to the information in Option 1 (for those which are subject to CCRA mutual recognition).
( ) 3 Do not publish any information.
Attachment of document proving the corporate status (select one of these options):
( ) Attached to this application
( ) Submitted with the previousapplication
Reception date of application:
Reception number:
( ) Attachedto anotherapplication formsubmitted on the same day

[1]Each item in this application is described as it is in the Certificate, etc., so it shall be accurately provided.

[2]The name and contact information for the person who is in charge ofthe application work with the Certification Body shall be provided. It is possible to assign a deputy (one person) as needed.

[3]The name of the developer of the product shall be given even if it is the same as the applicant.

[4]When confidential information needs to be provided from other corporationsother than the applicant for composite evaluation, etc., and the Non-Disclosure Agreement needs to be concluded, all the names of the entities shall be provided.

[5] If there are evaluation methodologies to be referenced other than the CC/CEM, a check shall be given for “Other,” and the name of the document to be referenced shall be provided.

[6]The applicant shall select “Hardware” in case of the product that requires hardware-based attack methods or vulnerability analyses. Otherwise, the applicant shall select “Software.” If this selection is unclear, the applicant shall contact the Certification Body in advancefor consultation.

[7]If there are products that are similar to this application or can be referenced among products that have been applied by the applicant in the past, check “Yes” and provide detailed information.

[8]Note that with application for non-publication of information, it is not allowed to change to publication (from 3 to 2, from 3 to 1, or from 1 to 2).When requesting publication of information of a product in evaluation, a“Request for Publication of Product in Evaluation (CCM-02-A Form 11)” shall be submitted. Publication cannot be requested if “3” is selected.

[9]This information is described in the “Supplier”field in the Certified Products List.