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.