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.
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