APPLICATION FORM FOR ISSUE OF DIGITAL SIGNATURE CERTIFICATE [CD1] 

 

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.

  

 [CD1]APPLICATION FORM FOR ISSUE OF DIGITAL SIGNATURE CERTIFICATE