Information-Technology Promotion Agency, Japan

CCM-02-A Form 1-2

Application for Certification (PP)[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).”

PP name:
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 PP author[3]:
Name of responsible manager (department):
Contact information (postal code, address, telephone, e-mail):
Procurement entity using thePP[4]:
Name:
( ) No procurement entity
( )
( ) “Name of the applicant” is described as “Name of Protection Profile 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 ( )
Assurance package:
Name of existing certified PP for conformance (if applicable):
Product area[6]:
( ) Software
( ) Hardware (smart cards, etc.)
Is there any related PP?[7] / ( )Yes
Certification number (Reception number for a PPin evaluation):
PP name:
( ) No
PPoverview:
Publication of certification information[8] (select one of these options):
( ) 1 Publishing only the overview of the PP, the name of the applicantand the name of the Evaluation Facility.
( ) 2 Publishing the PP 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( ) 3 Do not publish any information.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 previous application
Reception date of application:
Reception number:
( ) Attachedto another application 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. If the billing destination of the application fee is different from that of the applicant, consult with us in advance.

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

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

[4]This information is not disclosed. The name of the procurement entity shallbe given even if it is the same as the applicant. A check shall be given in the parenthesis (X) for “No procurement entity” if there is no procuremententity, and write its reason in the parenthesis ( ).The application may not be accepted if the procurement entity is not clearly 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 PP of the product that requires hardware-based attack methods or vulnerability analyses. Otherwise, the applicant shall select “Software.”

[7]If there are PPs that are similar to this application or can be referenced among PPs 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 to1, or from 1 to 2).When requesting publicationof information of a PP 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.