APPLICATION FORM FOR ISSUE OF DIGITAL SIGNATURE CERTIFICATE

APPLICATION FORM FOR ISSUE OF DIGITAL SIGNATURE CERTIFICATE

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APPLICATION FORM FOR ISSUE OF DIGITAL SIGNATURE CERTIFICATE (English)

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(Hindi) APPLICATION FORM FOR ISSUE OF DIGITAL SIGNATURE CERTIFICATE

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Form for Application for Issue of Digital Signature Certificate for Individual/Hindu Undivided Family applicant

1.Full Name* (Name of the Karla in case of Hindu Undivided Family)

Last Name/Surname ............................................

First Name ............................................

Middle Name ............................................

2. Have you ever been known by any other name? If yes,

Last Name/Surname ............................................

First Name ............................................

Middle Name ............................................

3.Address

Residential Address* ............................................

Flat/Door/Block No. ............................................

Name of Premises/Building/Village ............................................

Road/Street/Lane/Post office ............................................

Area/Local/city/Taluka/Sub- Division ............................................

Town/City/District ......................................…..

State/Union Territory ..................PIN ……………

Telephone No. ........................................

Fax No. ........................................

Mobile Phone No. .........................................

Office Address* .........................................

Name of Office ........................................

Flat/Door/Block No. .........................................

Name of Premises/Building/Village ...........................................

Road/Street/Lane/Post office ............................................

Area/Locality/Taluka/Sub- Division ............................................

Town/City/District ............................................

State/Union Territory ....................PIN…………… 

Telephone No. ............................................

FaxNo. ............................................

4. Address for Communication

Tick as applicable A or B

5. Father's name

Last Name/Surname ............................................

First Name ............................................

Middle Name ............................................

6. Sex* (For individual applicant only) Tick as applicable: Male/Female

7. Date of birth (dd/mm/yy) ............................................

8. Nationality* ............................................

9. In case of foreign national, visa details ............................................

10. Credit Card Details

Credit Card Type ............................................

Credit Card No. ............................................

Issued by ...................................……. 

11. E-Mail Address ............................................

12. Web URL Address ............................................

13. Passport Details #

Passport No. ............................................

Passport issuing authority .....................………………

Passport Expiry date (dd/mm/yyyy) ............................................

14.Voter's Identity Card No. # ............................................

15. Income-tax PAN No. # ............................................

16. ISP Details

ISP Name* ............................................

ISP's Website address, if any ............................................

Your user name at ISP if any ............................................

17Personal Web Page URL address if any ............................................

For Company/Firm/Body of Individuals/Association of persons/Local Authority

18. Registration Number* ............................................

19. Date of Incorporation/Agreement/Partnership* ............................................

20. Particulars of Business, if any*

Head Office ............................................

Name of Office ............................................

Flat/Door/Block No. ............................................

Name of Premises/Building/Village ............................................

Road/Street/Lane/Post office ............................................

Area/Locality/Taluka/Sub-Division ............................................

Town/City/District ............................................

State/Union Territory ........................PIN……….. 

Telephone No. ............................................

Fax No. ............................................

Web Page URL Address if any ............................................

No. of Branches .………………………….....

Nature of Business ............................................

21.Income-tax PAN No.* ............................................

22. Turnover in the last financial year Rs. ............................................

23.Names, Addresses, etc. of Partners/Members/Directors (For Information about

more persons, please add separate sheets) in the format given in the next page)*

Details of Partners/Members/Directors

No of Partners/Members/Directors

Full Name

Last Name/Surname ............................................

First Name ............................................

Middle Name ............................................

Address ……………………………..

Flat/Door/Block No. ............................................

Name of Premises/Building/Village ............................................

Road/Street/Lane/Post office ............................................

Area/Locality/Taluka/Sub-Division ............................................

Town/City/District ............................................

State/Union Territory ....................PIN…………..

Telephone No. ............................................

Fax No. .....…………..………………. 

Mobile Phone No. ............................................

Nationality ............................................

In case of foreign national, Visa details ............................................

Passport Details #

Passport No. ............................................

Passport issuing authority ............................................

Passport Expiry date (dd/mm/yyyy) ............................................

Voter's Identity Card No. # ............................................

Income-tax PAN No. # ............................................

E-Mail address ............................................

Personal Web Page URL, if any ............................................

For Government Organisations/Agencies

24. Particulars of Organisation/Agency*

Name of Organisation ............................................

Administrative Ministry/Department ............................................

Under State/Central Government ............................................

Flat/Door/Block No. ............................................

Name of Premises/Building/Village ............................................

Road/Street/Lane/Post office ............................................

Area/Locality/Taluka/Sub-Division ............................................

Town/City/District ............................................

State/Union Territory .................PIN …………….

Telephone No. ............................................

Fax No. ............................................

Flat/Door/Block No. ...............………………….. 

Name of Premises/Building/Village ............................................

Road/Street/Lane/Post office ............................................

Area/Locality/Taluka/Sub-Division ............................................

Town/City/District ............................................

State/Union Territory .....................PIN…………. 

Telephone No. ............................................

Fax No. ............................................

Web Page URL Address ............................................

Name of the Head of Organisation ............................................

Designation ...........................................

E-Mail Address ...........................................

25. Bank Details

Bank Name* ........………………………..

Branch* ............................................

Bank Account No.* ...........................................

Type of Bank Account* ............................................

26. Type of Digital Signature Certificate required*

27.Any other detail ............................................

Date Signature of the Applicant

……………………………………………………………………………………………….

Instructions

1. Columns marked with* are mandatory as applicable.

2. For the columns marked with #, details for at least one is mandatory.

3.Column Nos. 1 to 17 are to be filled by individual applicants.

4.Column Nos. 18 to 23 are to be filled up, if applicant is a Company/Firm/Body of Individuals/Association of Persons/Local Authority.

5.Column No. 24 is to be filled up, if applicant is a Government Organization.

6.Column Nos. 25 and 26 are to be filled by all applicants.