Order form - Subscription to LuxTrust services
SmartCard PRO valid for 3 years
For official use only
Order form : OK NOK Identification applicant : OK NOK
ID document(s) : OK NOK Identified by : _________(code empl)
Articles of Association : OK NOK Payment : OK
Commercial Register : OK NOK Encoder : _________(code empl)
Signatory authorisations OK NOK Validator : _________(code empl)
Part 1 : Order information
Order no. (reference to be indicated when
making payment) : 23008963325 Rate type : CREDIT CARD
Device : SmartCard PRO Price excl. VAT 187.18 EUR
VAT 17.0 % : 31.82 EUR
Order date : 30/06/2025
Identification Type : Video ID TOTAL : 219.00 EUR
Part 2 : Information (particulars) contained on the certificate
Data of holder * :
N.B.: The entries made in the fields marked with an * must correspond exactly to the particulars on the certificate holder’s ID.
First (and middle) name * : Vojtech
Surname * : Kugel
Nationality * : LUXEMBOURG
E-mail address (optional) : kugel@[Link]
2nd e-mail address (optional) : kugel@[Link]
Holder type : Professional person (default)
Professional Certificate Administrator**
** An Administrator (appointed by the company) can revoke any certificate issued on behalf of the company
(or the institution) without the prior consent of the certificate
Data of the company (or institution) :
Name / business name : N+C (Luxembourg) S.à r.l.
Registered office : LUXEMBOURG
Identifier (VAT [Link] RCSL) : B264396
Department or position/title of certificate
holder within the company (optional) : Shareholder
Part 3 : Information (data) not contained on the certificate
Data of holder :
Date of birth (dd/mm/yyyy) : 25/07/1990
[Link] Page 1 of 3
Order n° 23008963325
Activation code : 23250
(Recommandation : last 5 characters of the ID document – letters and numbers only)
Phone no. : +352691109289
(Enables us to get in touch with you should there be a problem with your order)
Certificate be published in the directory : Yes No
(The directory ([Link] is public and is comparable to a phone book for certificates.)
E-mail address for notifying you kugel@[Link]
Data of the company (or institution) :
Phone number : +352691109289
Email address : kugel@[Link]
Billing Address : Address for delivery of the device and the
activation instructions :
Company : N+C (LUXEMBOURG) S.A R.L. Name of addressee : Vojtech
EU VAT reg. no. : LU34381306 Kugel
Email address : kugel@[Link]
Street and house no. 38 RUE SAINTHE ZITHE same as Billing address
Address line 2 : 38 RUE SAINTHE ZITHE
Postcode and town : 2763 LUXEMBOURG
Country : LUXEMBOURG
Part 4 : Signature *
Holder : Persons empowered to sign on behalf of the company or institution to
authorise the issue of a device on behalf the certificate holder :
Name : ________________________________
Signature : ________________________________ Name 1 : _________________________________
Date/place ____/____/_______,______________ Signature 1 _________________________________
Date/place ____/____/_______,______________
Legal guardian (where the certificate
(delete as applicable) holder is a minor)
Nom : ________________________________ Name 2 : _________________________________
Signature : ________________________________ Signature 2 : _________________________________
Date/place ____/____/_______,______________ Date/place ____/____/_______,______________
By signing this, the undersigned(s) authorise the financial institution
By signing this, the undersigned authorises his or her financial of their company (or institution) to use the ID information and the
institution to use the ID information available to it for registration information pertaining to authorised signatories available to it for
purposes for the device. subscription and registration purposes of the service.
* Signing this order form will result in the creation of a Contract and in your acceptance of LuxTrust S.A.’s General Sales Terms and Conditions
([Link]) for the service for which a subscription is being obtained, LuxTrust S.A.’s Certification Policy (CP) and LuxTrust S.A.’s Certification
Practice Statement (CPS), these items forming an integral part of the Contract. In the event of any contradiction or inconsistency between the
documents comprising the Contract, the documents shall apply in the following descending order of importance: (a) the CP; then (b), the CPS; then
(c) the General Sales Terms and Conditions (repository.
This order form and the requisite documents (Annex 1) are to be submitted to the registration
authority (Annex 2).
[Link] Page 2 of 3
Order n° 23008963325
Annex 1 : Documents to be submitted to the registration authority
Order for PRO certificate for a company :
Documents :
1/ Order form, completed, signed and dated in original by the certificate holder and the company’s authorised legal
representatives.
2/ Copy of front and back of the undersigneds’ identity card or passport.
3/ Company’s articles of association and signatory authorisations.
4/ Extract from the Commercial Register no older than 6 months. [Link]
Order for PRO certificate for self-employed professionals :
Documents :
1/ Order form, completed, signed and dated in original.
2/ Copy of front and back of the undersigned’s identity card or passport.
3/ Certification or official letter no older than 6 months issued by the competent professional/industrial association or
organisation.
4/ Copy of the signatory authorisations applicable to third parties.
A single copy of 3 and 4 suffices when accompanying one or more orders sent to the same RA at the same time.
Order for PRO certificate for an institution :
Documents :
1/ Order form, completed, signed and dated in original by the certificate holder and the institution’s authorised
legal representatives(*).
2/ Copy of front and back of the undersigned’s identity card or passport.
3/ Copy of the institution’s charter or deed.
4/ Copy of the official decision with person empowered to sign on behalf of the institute.
A single copy of 3 and 4 suffices when accompanying one or more orders sent to the same RA at the same time.
Annex 2 : Processing of documents
My identity has already been verified :
I will send the documents by postal mail to the registration authority selected by me when
placing my order.
My identity has not yet been verified by LuxTrust or another registration authority :
I will report in person to a registration authority, which will verify my identity.
Adresses of registration authorities : [Link]
Next step :
You will be informed by email concerning the instructions to proceed when you order has been processed.
Need help ?
Refer to the online help section on [Link] or contact the registration authority selected by you ([Link]).
[Link] Page 3 of 3