E-tendering - Digital Signature Certificates - Reg
DIGITAL CERTIFICATE FOR INDIVIDUAL - APPLICATION FORM PLEASE FILL IN BLOCK LETTERS ONLY For form filling please follow the instruction in http://www.e-mudhra.com/instruction.html Application ID (For Office Use Only) Encryption Signature CLASS TYPE VALIDITY Class 2 Signature 1 Year Class 3 Encryption 2 Years Affix recent passport size photograph of the applicant duly signed across USB TOKEN Required Not Required APPLICANT INFORMATION Applicant Details L A S T N A M E Date of Birth Communication Address F Gender Residence I R S T Male N A M E Female M I D D L E N A M E Nationality Office (as per the address proof submitted) City State Pin code Telephone Mobile Email ID PAN Declaration I hereby agree that I have read and understood the provisions of e-mudhra Certification Practice Statement (CPS) and the subscriber agreement and will abide by the same. The information provided in this Digital Signature Certificate request form is true and correct to the best of my knowledge and I accept publishing my certificate information in e-Mudhra repository. Date Place Seal & Stamp (If any) Signature of the applicant TO BE FILLED BY RA OFFICE ONLY I declare that the applicant has provided correct information in this application form. I have checked and verified the application form and supporting documents. Date Place RA Name, Code & Seal Signature of RA Checklist / Document Proof: Identity Documents (Any one of below) Passport Driving License PAN Card Aadhaar Card Bank Account Passbook Government ID Card Post Office ID Card ID Number Checklist / Document Proof: Address Documents (Any one of below) Telephone Bill Water Bill Gas Connection Electricity Bill Passport Vehicle Registration Certificate Aadhar Card Driving License Bank Statement Voter ID Card Service Tax / VAT / Sales Tax Registration Certificate Property Tax / Corporation / Municipal Corporation Receipt eMudhra Consumer Services Limited, 3rd Floor, Sai Arcade, 56 Outer Ring Road, Deverabeesanahalli, Opp Intel, Bangalore 560 103. Page 1 of 1 Karnataka. Phone : +91 80 4336 0000 Fax : +91 80 4227 5306. Email : [email protected] Website: www.e-Mudhra.com. VERSION 2.1 Cl ass2 I ndi vi dualCer t i f i cat e Regi st r at i on Form f orCl ass2 Di gi t alCert i f i cat e Cust omerI dent i f i cat i onNumber:_______________________________ ( f orof f i ceuseonl y) Val i di t y 1Year 2Year Type Onl ySi gni ng Si gn& Encr ypt Af f i xr ecent passpor t si zephot ogr aph oft he appl i cant Appl i cantName Sur name Fi r stName Mi ddl ename Emai lI D Dat eofBi r t h D D M M Y Y Y Y Appl i cantt osi gnacr oss t hephot ogr aphext ended t oappl i cat i onf or m e-S afe , e-S ecure , e-S ure Resi dent i alAddr ess ( Asment i onedi nat t ached suppor t i ng) Town/ Ci t y/ Di st r i ct St at e/ Uni onTer r i t or y Cont actNo. PI N I dent i t yDet ai lofAppl i cant PAN * Car d Post of f i ce I D Car d PH MO Pl eas et i c kanyoneandenc l os et hec opyofs ame Dr i vi ng Li cense Passpor t Govt . 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Dat e: Pl ace: Ver i f i edby( n) CodeOf f i ce Si gnat ur eofAppl i cant ForLRA useonl y Al lDocument sChecked& Ver i f i edby: Seal& Si gnat ur e LRAName,Seal& Si gnat ur e ( n) Tol lFr ee:1800–233–1010 Page / /1-2 Cl ass2 I ndi vi dualCer t i f i cat e Regi st r at i on Form f orCl ass2 Di gi t alCert i f i cat e Cust omerI dent i f i cat i onNumber:_______________________________ ( f orof f i ceuseonl y) Document sRequi r edf orVer i f i cat i on Checkl i stoft hedocumentt obesubmi t t edwi t hAppl i cat i on 1 At t est edcopyofanyonedocument saspr oofI dent i t y .( Pl easet i ckt heonesubmi t t ed) PAN Car d Passpor t PostOf f i ce I D Car d OR Dr i vi ng Li cense OR CopyofBankAccountPassbookcont ai ni ngphot o& si gned byappl i cantwi t hat t est at i onbyconcer nedBankOf f i cer OR OR Gover nment I D Car d OR e-S afe , e-S ecure , e-S ure Documentaspr oofofAddr ess( Pl easet i ckt heonesubmi t t ed) 2 At t est edcopyofdocument saspr oofofAddr ess.( Pl easet i ckt heonesubmi t t ed) Tel ephone Bi l l OR Vot er I D Car d OR Passpor t El ect r i ci t y Bi l l OR Wat er Bi l l OR OR BankSt at ement at t est edbyt heBank Dr i vi ng Li cense/ RC OR Gas Connect on OR Pr oper t yTax/Cor poat i onTax Muni ci palCor por at i onRecei pt OR Ser vi cesTax/VATTax/ Sal esTaxReg.Cer t i f i cat t e OR PaymentDet ai l s( Appl i cabl ef orappl i cantobt ai ni ngDSC f r om anyof( n) CodeOf f i ces) Cheque/D. D.t obeDr awni nf avourof“ ( n) CodeSol ut i ons,Di vi si onofGNFC Lt d. ”( Chequeshoul dbe“ Payabl eatPar ” ) Dat e: ( n) CodeOf f i ces BankName: DD /ChequeNo.: Cor por at eOf f i ceAhmedabad:07940007300 Amount: dscsal es@ncode. i n Mumbai Del hi Bangal or e Chandi gar h Sur at 02222048908 01126452279/ 80 08025272525 01722707732 02613003690 mumbai sal es@ncode. i n nor t hsal es@ncode. i n sout hsal es@ncode. i n punj absal es@ncode. i n sur at sal es@ncode. i n Tol lFr ee:1800–233–1010 Page / /2-2 ( n)
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