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    3i Infotech Company

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    giri xda
    This document is an application form for an organization to apply for a digital signature certificate from e-Mudhra. It requests information such as applicant details, organization details, payment details, documents required for verification. The applicant must declare that they have read and understood e-Mudhra's certification practices and will abide by the subscriber agreement. An authorization letter from the organization is also required authorizing the applicant to apply for the certificate on the organization's behalf.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    3i Infotech Company

    Uploaded by

    giri xda
    193 views3 pages
    This document is an application form for an organization to apply for a digital signature certificate from e-Mudhra. It requests information such as applicant details, organization details, payment details, documents required for verification. The applicant must declare that they have read and understood e-Mudhra's certification practices and will abide by the subscriber agreement. An authorization letter from the organization is also required authorizing the applicant to apply for the certificate on the organization's behalf.

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    3i Infotech Company

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    This document is an application form for an organization to apply for a digital signature certificate from e-Mudhra. It requests information such as applicant details, organization details, payment details, documents required for verification. The applicant must declare that they have read and understood e-Mudhra's certification practices and will abide by the subscriber agreement. An authorization letter from the organization is also required authorizing the applicant to apply for the certificate on the organization's behalf.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    193 views3 pages

    3i Infotech Company

    Uploaded by

    giri xda
    This document is an application form for an organization to apply for a digital signature certificate from e-Mudhra. It requests information such as applicant details, organization details, payment details, documents required for verification. The applicant must declare that they have read and understood e-Mudhra's certification practices and will abide by the subscriber agreement. An authorization letter from the organization is also required authorizing the applicant to apply for the certificate on the organization's behalf.

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    © All Rights Reserved
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    APPLICATION FOR DIGITAL SIGNATURE CERTIFICATE

    (FOR ORGANISATION)
    Application ID Number (For office use only):
    Instructions:
    1. Please fill the form in BLOCK LETTERS only. Affix recent passport
    2. [*] MARKED Fields are Mandatory.
    size photograph of the
    3. Any discrepancy or inconsistency in the form will lead to delay and / or rejection.
    4. Attestation of documents by any: Public Notary OR Gazetted Officer OR Bank Manager OR Company Secretary/Director OR applicant.
    present originals to our Registration Authority for verification & attestation.
    5. All subscribers are advised to read Certification Practice Statement of e-Mudhra available at www.e-Mudhra.com Applicant to sign across
    6. At Par Cheque/Demand Draft to be drawn in favour of 3i Infotech Consumer Services Ltd. the photograph
    7. Applicants for Class III shall present themselves at the RA location where the registration form for Digital Signature extended to application
    Certificate was sent, for verification of physical presence.
    8. Legal proceedings will be initiated against cheque bounce. form

    1A. CERTIFICATE CLASS:* 1B. CERTIFICATE TYPE:* 2. CERTIFICATE VALIDITY:* 3. USB TOKEN:*
    Class 2 Gold Organisation Signature
    1 Year Required
    Class 3 Platinum Organisation Encryption
    Class 3 Device/Server SSL Server 2 Years Not Required

    APPLICANT DETAILS* (As per applicant’s valid ID Proof at Sl.No.11 below)


    4. Name:* First Name Middle Name Last Name/Surname
    Mr. Ms. Dr.
    5. Date of Birth:* D D M M Y Y Y Y 6. Gender:* Male Female
    7. Nationality:* 8. Residential Status:* Resident Non-Resident

    CONTACT DETAILS*
    9. Office Address:*
    Organisation Name
    Designation
    Department
    Flat/Door/Block No.
    Name of the Premises/Building/Village
    Road/Street/Lane/Post Office
    Area/Locality/Taluka/Sub-division
    Town/City/District
    State/Union Territory
    Pincode
    Telephone No. (e.g.+91-80-23333333)
    Mobile No. (e.g.+91-9999999999)
    Fax No. (e.g.+91-80-23333333)

    IDENTIFICATION DETAILS*
    10. E-Mail ID:* (Valid and active E-mail ID to be
    included in the Digital Signature Certificate)
    11. a) PAN Number:*
    11. b) Valid Identity Details:* Driving Organisation
    Passport Voter’s ID PAN Card
    (Please tick any one and fill the ID number and License Id Card
    attach attested copy of ID proof)

    Version 1.2 Page | 1


    12. DETAILS REQUIRED IF APPLYING FOR SERVER CERTIFICATE
    ISP Name
    Domain Name
    Domain IP Address
    Physical Location (of Server Hosting)
    Services Offered on the website
    Name of registrar of Domain
    Domain registration validity (DD/MM/YYYY)
    ORGANISATION DETAILS*
    13. Organisation Details:* Corporate Office Head Office Registered Office Branch Office
    Organisation Name
    Registration Number
    Date of Incorporation/Proprietorship
    Commencement/Partnership Agreement
    Flat/Door/Block No.
    Name of the Premises/Building/Village
    Road/Street/Lane/Post Office
    Area/Locality/Taluka/Sub-division
    Town/City/District
    State/Union Territory
    Pincode
    Telephone No. (e.g.+91-80-23333333)
    Mobile No. (e.g.+91-9999999999)
    Fax No. (e.g.+91-80-23333333)
    Corporate Website (URL)
    PAN No. of Organization* (Attach photo copy)
    Organization’s Bank Account Details*
    Bank Name Account Type Savings Current
    Branch Name & Place Account Number
    PAYMENT DETAILS*
    14. Mode of Payment* Online Cheque/DD
    Online Payment Details Cheque/DD Payment Details
    Transaction/Reference No. Cheque/DD No.
    Bank Name Bank & Branch Name
    Account Type Account Type
    Amount Rs. Amount Rs.
    Date Date
    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.
    Place: Signature of the Applicant:
    Date: Name of the Applicant:
    Office Seal and Stamp:

    Version 1.2 Page | 2


    CHECK LIST OF ORGANISATION DOCUMENTS TO BE SUBMITTED ALONG WITH THE APPLICATION*
    a. True copy of any one (attested by Company Secretary OR Director OR Partner of the Organisation as applicable)
    Certificate of Incorporation Memorandum of Association Regd Partnership Deed Valid Business Licence
    b. True copy of any one (attested by Company Secretary OR Director OR Partner of the Organisation as applicable)
    Annual Report Latest Income Tax Return Latest Organisation Bank Statement of Income issued
    details from the Bank by Chartered Accountant
    c. Attested Copy of the Organisation PAN Card
    d. Authorization letter in favour of the certificate applicant from the Organisation as per format below
    e. Domain Name registration proof from the registrar of Domains (If applying for Server Certificate)

    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.
    RA Name:
    Signature:

    Place:
    Date: RA Seal & Stamp

    AUTHORISATION LETTER FORMAT*


    (This Authorisation Letter is required on the Organization’s letterhead)
    To,
    e-Mudhra, 3i Infotech Consumer Services Limited, Date: D D M M Y Y Y Y
    XXXXXXXX

    Dear Sir,

    Sub: Authorisation letter for obtaining Digital Signature Certificate.

    This is to certify that Mr. /Mrs./Miss.______________________________________ (Certificate applicant) has provided


    correct information in the “Application Form for issue of Digital Signature Certificate” to the best of my knowledge and
    belief vide application form dated DD-MM-YYYY. I hereby authorize him/her, on behalf of our Organisation to apply for
    obtaining the following Class of Digital Signature Certificate issued by e-Mudhra.
    Class 2 Gold Organisation Class 3 Platinum Organisation Class 3 Device / Server
    Details of Executive Authorizing the Applicants:
    Signature:
    Name:
    Designation:
    Department:
    Office Seal and Stamp

    CONTACT DETAILS
    e-Mudhra
    3i Infotech Consumer Services Limited,
    4th Floor, Prince Technopark,# 10, Rajiv Gandhi Salai,Thoraipakkam, Chennai 600 096,Tamilnadu, India
    Phone: +91 44 3065 3500||Fax: +91 44 3065 3100
    Email: info@e-Mudhra.com||Website: www.e-Mudhra.com

    Version 1.2 Page | 3

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