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.