APPLICATION FORM FOR ISSUE OF DIGITAL SIGNATURE CERTIFICATE

 

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.