For Offline Kyc: Pingala Raman Venkat AKLPP5827B 30-06-1961 9831050345

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Digital Signature Application Form

FOR OFFLINE KYC

Application ID Class Class 3 Certificate Type Signature


2545928 Application Type Individual Validity 2 Year

Subscriber Details

Applicant Name: PINGALA RAMAN VENKAT

PAN: AKLPP5827B Affix Passport Size Photo


With Cross Sign On It

Date Of Birth: 30-06-1961 Gender:

Aadhaar: N/A Mobile: 9831050345

Email ID: cemtech.epl@gmail.com

Address: S/O Pingala Sarveswar Rao,433/1,SARAT CHATTERJEE ROAD,Haora Corporation,BGarden,

City: HAORA State: West Bengal Pincode: 711103

EKYC Code: acea04c2040948a9059ee8d3696c03ca

Declaration by Applicant

I confirm that the information provided by me in the digital signature application form is correct. I am aware that Section
71 of the IT act stipulates that if anyone makes a misrepresentation or suppresses any material fact from the CCA or CA
for obtaining any DSC, such person shall be punishable with imprisonment up to 2 years or with fine up to one lakh
rupees or with both.

I give my consent to VSign to use my KYC Account data for the purpose of this digital signature application & also
consent to receiving SMS and eMail communication from VSign regarding this application from time to time.
I also allow VSign to publish my certificate information in their repository.

I have read and understood and agree to the terms and condtions mentioned in the VSign CPS & the subscriber
agreement.

Applicant Signature Registration Authority Details

migrategst1@gmail.com
Date: RA Code: JHUNJHUNWALA GAURANGI

Place: 8420298555

(This document is esigned by the applicant, in accordance to the Second Schedule of Information Technology Act.)
VERASYS TECHNOLOGIES PRIVATE LIMITED, 2nd Floor Bhavna Building, V.S. Marg Prabhadevi Mumbai- 400025
Website: www.vsign.in, Contact: 91 22 43156000, Email: info@vsign.in

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