IESO System Access Request and Identity Management Form

IESO System Access & Identity Management – (Form 1276)USERID_______________Part 5: Participant Signatures5.1 Market Participant Authorized Signatory declaration:Please note: this is the person whose signature is on the Participation Agreement,Application for Authorization to Participate, Certificate Subscriber Agreement (CSA) orIncumbency LetterThe Market Participant declares that the information contained in this request is true and has read, understood, and acceptsthe responsibilities, obligations and liabilities with the use of the IESO Digital Certificate as described in the IESO CertificateSubscriber Agreement; and where applicable has approved the USER ID account creation or deactivation; issuance, recoveryor revocation of a digital certificate; or change system access privileges for the identified Individual or Application Subscriber.Signature ofAuthorized SignatoryPrint Name at City/Province Date/Time5.2 Sign to Identity Proof:A new user, a new Market Participant Registration Officer (MPRO), or for a name changeCheck One: Declaration ofMarket Participant Registration Officer (MPRO) orIESO Identity Management Officer orNotary Public (include stamp or seal)I have verified the identity of the subject individual or custodian based on the identity verificationrequirements in Part 6 of this form.Signature of MPRO, IESOIdentity Management Officeror Notary PublicPrint Name at City/Province Date/Time5.3 Sign for Recovery of Digital CertificateI declare that the information contained in this request is true and I approve the recovery ofa digital certificate for the identified Individual or Application Subscriber.Signature of MPRO orAuthorized SignatoryPrint Name at City/Province Date/Time5.4 New Market Participant Registration Officer Declaration (Sign for MPRO EnrolmentOnly)I declare that the information contained in this request is true and I understand and accept the responsibilities associatedwith the role of Market Participant Registration Officer as set out in the Certificate Subscriber Agreement between the MarketParticipant and the Independent Electricity System Operator and the Identity Management Operations Guide.Signature of MPRO to beenrolledPrint Name at City/Province Date/TimeIMO-FORM-1276 v.18.0 1REV 09-0312 Confidential Page 5