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Page 1: NOTE Upon receiving an Auto generated email or …...Male Female Nationality L A S T N A M E Date of Birth Gender City State Pin code PAN of Applicant Mobile DECLARATION BY APPLICANT

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the form are true and correct to my knowledge & belief. I hereby authorise D. Sign Softech

Ensure to sign in Declaration section of the form. (With Blue ink only.)

Ensure to sign in Authorization section of the form. (With Blue ink only.)

(In other than Black ink.)

(In other than Black ink.)

���������� �Authorised Signatory of Organisation. (In other than Black ink.)

(With Blue ink only.)

(With Blue ink only.)

The Organisation Proof (As mentioned in form) should be compulsorily

NOTE�

Unique email ID and unique Mobile number should be used for each applicant.

Photograph should be colored and on photo paper only.

Upon receiving an Auto generated email or SMS from e-Mudhra, the applicant has to do mobile verification from her/his mentioned mobile number in the application form. The Applicant has to provide correct details as filled by her/him in the application form. If wrong details provided during this verification process, your DSC will be rejected and you have to submit documents and payment again. So it is suggested to you to keep a copy of application form in front of you while doing this process.

Option 1 - Voice: Call eMudhra mobile verification number 080-43460300 and answer 2-3 questions to confirm the identity of the applicant. (From Monday – Friday 9.30 am - 6.00 pm and Saturday 9am - 05.00 pm)

Option 2 - Text : SMS to eMudhra Self-Service number in specific format and complete the verification. eMudhra SMS based verification number: +91-9945211399Format: VERIFY <Application ID> <Birth Date in DDMMYYYY format>Example: verify 1234567 09121960

Page 2: NOTE Upon receiving an Auto generated email or …...Male Female Nationality L A S T N A M E Date of Birth Gender City State Pin code PAN of Applicant Mobile DECLARATION BY APPLICANT

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Group ‘A’ Gazetted officers include

a) All India services though posted to statesb) Promotes from states to the cadre of Assistant

commissioner and abovec) Police officers (Circle Inspector and above)d) Additional District Civil surgeonse) Executive Engineers and abovef) District Medical Officer and aboveg) Lt. Col and aboveh) Principals of Government Colleges and abovei) Readers and above of Universitiesj) Patent Examiner etc.

Group ‘B’ Gazetted officers include

a) Section Officerb) BDO(Block Development Officer)c) Tahsildard) Junior Doctors in Government Hospitalse) Assistant Executive Engineerf) Lectures in Government collegesg) Headmaster of Government high schoolsh) 2nd Lieutenant to Majori) Magistrate

Page 3: NOTE Upon receiving an Auto generated email or …...Male Female Nationality L A S T N A M E Date of Birth Gender City State Pin code PAN of Applicant Mobile DECLARATION BY APPLICANT

Male Female Nationality

L A S T N A M E

Date of Birth Gender

City

State

Pin code

MobilePAN of Applicant

DECLARATION BY APPLICANTI 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 form is true & correct to the best of my knowledge. I accept publishing my certificate information in e-Mudhra repository. I am aware of risksassociated in case of Class 1 Certificate,when storing the private key on a device other than a FIPS 140-1/2 validated cryptographic module.

Date

Place Signature of the applicant

RA Name, Code & Seal Signature of RA

APPLICANT INFORMATION F I R S T N A M E M I D D L E N A M E Affix recent passport

size photograph of the applicant duly

signed across

APPLICATION FORM - SIGNATURE / ENCRYPTION CERTIFICATE

FOR ORGANISATION

PLEASE FILL IN BLOCK LETTERS ONLY. ALL FIELDS ARE MANDATORY

Page 1 of 1 Version 2.8

Date

Org Address

Email ID

More Instructions available at: http://www.e-mudhra.com/instruction.html

1 Year

Signature Encryption Combo

CLASS:

TYPE:

VALIDITY:

2 Years

TO BE FILLED BY RA OFFICE ONLY

D D M M Y Y Y Y

OrganisationName

Department

DOCUMENT PROOF (attested by Authorized Signatory of the Organization)

eMudhra Limited, 3rd Floor, Sai Arcade, 56, Outer Ring Road, Deverabeesanahalli, Opp Intel, Bangalore 560 103. Karnataka. Phone : +91 80 4336 0000 Fax : +91 80 4227 5306. Email : [email protected] Website: www.e-Mudhra.com.

(As in ID proof | Blue Ink Only)

AUTHORIZATIONI hereby authorize the above applicant, on behalf of our

Organisation to apply for obtaining the Digital Signature/ Encryption Certificate issued by e-Mudhra

Class 1 Class 2 Class 3

Authorized Signatory (Sign and Seal)

I declare that the applicant has provided correct information in this application form . I have checked and verified the application form and supporting documents. I herebytake full responsibility for any wrong verification made, or wrong documents submitted for the application.

Organization Type: Company Partnership Proprietorship AOP/BOI LLP NGO/TRUST

Document Name Company Partnership Proprietorship AOP/BOI LLP NGO/TrustCopy of Applicant’s Organizational ID Card / Letter from Organization / Pay Slip

Copy of Organizational PAN Card

Copy of Bank Statement (First 2 Pages)

Copy of Incorporation/Registration Certificate

Copy of AOA & MOA / Rules / Bye laws (First 2 Pages)

Copy of Last Income Tax Return / Audit Report & Annual Return / Self Affidavit with reason,if not available (First 2 Pages)

Copy of Partnership Deed / Trust Deed / LLP Agreement containing the List of Partners / Signatories (2 Pages)

Copy of Business Registration Certificate (S&E / ST / VAT)

Proof of Authorized Signatory (Board Resolution)

Authorized Signatory Organizational ID Card / Self-Attested Letter of Organizational Identity

Copy of PAN Card of Applicant, if PAN provided * * * * * *

Application ID: (S) (E) (For Office Use Only)