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Digital Certificate Application Form

This document is an application form for an organization to apply for a digital signature or encryption certificate from e-Mudhra. It requests information about the applicant, organization, type of certificate and validity period. It requires documents to verify the applicant and organization identity such as PAN cards, bank statements, incorporation certificates and authorized signatory proof. The applicant and authorized signatory must declare that the information provided is true and correct and agree to the e-Mudhra CPS and subscriber agreement terms. The RA office verifies the application and documents.

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Jeherul Bhuyan
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114 views1 page

Digital Certificate Application Form

This document is an application form for an organization to apply for a digital signature or encryption certificate from e-Mudhra. It requests information about the applicant, organization, type of certificate and validity period. It requires documents to verify the applicant and organization identity such as PAN cards, bank statements, incorporation certificates and authorized signatory proof. The applicant and authorized signatory must declare that the information provided is true and correct and agree to the e-Mudhra CPS and subscriber agreement terms. The RA office verifies the application and documents.

Uploaded by

Jeherul Bhuyan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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* * * * * *

APPLICATION FORM - SIGNATURE / ENCRYPTION CERTIFICATE


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

PLEASE FILL IN BLOCK LETTERS ONLY. ALL FIELDS ARE MANDATORY


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

APPLICANT INFORMATION
Applicant AFFIX RECENT
Name PASSPORT SIZE OF
THE APPLICANT
Date of Birth D DMMY Y YY Gender Male Female
DULY SIGNED

Organisation
Name

Department

Org Address
CLASS:

Class 1 Class 2 Class 3

City Pin code TYPE:


State A S S A M Signature Encryption Combo
*671R Mobile
VALIDITY:
PAN of Applicant (NOTE : PAN No. is mandatory)
1 Year 2 Years 3 Years
Email ID

DOCUMENT PROOF (attested by Authorized Signatory of the Organization)


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

Document Name Company Partnership Proprietorship AOP/BOI LLP NGO/Trust

Copy of Organizational PAN Card, If GST No. not provided

Copy of Recent Bank Statement / Bank Certificate, If GST No. not provided

Copy of Incorporation Certificate, If GST No. not provided

Copy of Business Registration Certificate (S&E / etc)

Copy of Partnership deed containing list of Partners / Authorization Letter

Proof of Authorized Signatory (List of Directors / Board Resolution / Resolution)

Authorized Signatory ID Proof (Organizational ID Card / PAN Card / etc) ( If applicant is not a
proprietor )

Copy of Applicant PAN Card

DECLARATION BY APPLICANT AUTHORIZATION


I hereby agree that I have read and understood the provisions of e-Mudhra Certification Practice Statement (CPS) I hereby authorize the above applicant, on behalf of our
and the subscriber agreement and will abide by the same. The information provided in this form is true & correct to Organisation to apply for obtaining the Digital Signature/
the best of my knowledge. I accept publishing my certificate information in e-Mudhra repository. I am aware of risks Encryption Certificate issued by e-Mudhra. I hereby confirm
associated in case of Class 1 Certificate,when storing the private key on a device other than a FIPS 140-1/2 validated the Identity of the above Individual and My identity
cryptographic module. (Authorized Signatory). I’m the Authorized Personnel to
to certify the Identity on behalf of the Organization.
Date ........../........../20.....
Signature of the applicant
Place BARPETA ROAD (As in ID proof | Blue Ink Only) Authorized Signatory (Sign and Seal)
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. I hereby
take full responsibility for any wrong verification made, or wrong documents submitted for the application.

Date ........../........../20..... RA Name, Code & Seal Signature of RA

eMudhra Limited, 3rd Floor, Sai Arcade, 56, Outer Ring Road, Deverabeesanahalli, Opp Intel, Bangalore 560 103.
Karnataka. Phone : +91 80 4615 6902 Fax : +91 80 4227 5306. Email : [email protected] Website: www.e-Mudhra.com.

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