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PND DIGISIGN103, 1st Floor, Simandhar, Wamanrao Sawant Road, Opp. Jana Seva Bank, Dahisar (E), Mumbai – 400068.
Tel: (022) 28284033 / 28282998 / 98209 44649 Email: [email protected] website: www.pnddigisign.com
INSTRUCTIONS / CHECKLIST
1.Please fill the form in BLOCK LETTERS & in BLUE INK ONLY2.The Certificate will be issued only if the application form is complete in all aspects.3.Along with the completed and signed application form, please attach following documents as mentioned below:
AttachmentsDocument 1 Attested Copy of all documents according to your organisation structure as listed on last
page. Organizational documents can be attested by Authorized signatory. Attestation inBLUE INK ONLY
Document 2 Attested Copy Applicant’s PAN Card & Authorizing Person’s PAN Card. [Attestationby the Gazetted Officer (List attached) / Bank Manager / Post Master), details of theattesting officer like designation, address and contact no. should also be mentioned.Signature of Attesting Officer in BLUE INK ONLY].
Document 3 Authorisation Letter to be signed by Other Director / Partner & Seal on form
Document 4 Attested Copy of IEC Certificate. Attestation procedure same as Document 2.
Document 5 Letter of Identity Proof by Organization in format attached with this form.
Latest Photograph of the Applicant to be pasted and Signed across.
Note: 1. In case tax return is not submitted, the Organization should provide a self-affidavit stating the reason.
2. In case, the organization name is different from that in PAN, the proof ofname change is required.
3. In case of Proprietor, any one Business License (like Shop & Establishment /VAT / Service Tax) is required.
4. Unique Email Address & Mobile Number is mandatory.
5. Mobile verification (Tele-Verification) to be done by applicant after processing of application.(If due to any reason mobile/tele-verification fails then Original Application will not be given back as it will besubmitted to company. Even amount will not be refunded.)
6. The authentication credentials to download the DSC would be sent through SMS ONLY on the Applicants
Mobile Number. Two SMS will be sent for two authentication credentials for Signing & Encryption DSC.
7. Video Recording will be done as per guidelines issued by emudhra.
PND DIGISIGN103, 1st Floor, Simandhar, Wamanrao Sawant Road, Opp. Jana Seva Bank, Dahisar (E), Mumbai – 400068.
Tel: (022) 28284033 / 28282998 / 98209 44649 Email: [email protected] website: www.pnddigisign.com
List of Group ‘A’ /Group ‘B’ Gazetted officersGroup ‘A’ Gazetted officers includei) All India services though posted to statesii) Promotes from states to the cadre of Assistant
commissioner and aboveiii) Police officers (Circle Inspector and above)iv) Additional District Civil surgeonsv) Executive Engineers and abovevi) District Medical Officer and abovevii) Lt. Col and aboveviii) Principals of Government Colleges and aboveix) Readers and above of Universitiesx) Patent Examiner etc.
Group ‘B’ Gazetted officers includei) Section Officerii) BDO(Block Development Officer)iii) Tahsildariv) Junior Doctors in Government Hospitalsv) Assistant Executive Engineervi) Lectures in Government collegesvii) Headmaster of Government high schoolsviii) 2nd Lieutenant to Majorix) Magistrate
(Notary & SEO Attestation will not acceptable)
Please make payment by Demand Draft in the favour of “PND DIGISIGN” or you can make payment byNEFT (Ask for Bank Details) and send the receipt of NEFT along with this form.
COST STRUCTURE OF KIT AS FOLLOWS:
TYPE DSC +SERVICE
USBTOKEN
DRIVERS/SOFTWARECD
VALIDITY MRPFOR 2YEAR
KIT 3 √ √ √ 2 Year 4500/-
PAYMENT DETAILS
Issue DD in favour of “PND DIGISIGN”Name of the applicant: ________________________________________________________________
DD No.: _________________ Dated ______________ Amount: _______________ for KIT _________
Drawn on ______________________________________________________________
Male Female Nationality
L A S T N A M E
Date of Birth Gender
City
State
Pin code
MobilePAN of Applicant
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 CERTIFICATE
FOR DGFT (EXPORT / IMPORT)
Application ID: (S) (For Office Use Only)
PLEASE FILL IN BLOCK LETTERS ONLY. ALL FIELDS ARE MANDATORY
Page 1 of 1 Version 2.8
Org Address
Email ID
More Instructions available at: http://www.e-mudhra.com/instruction.html
1 Year
CLASS:
TYPE:Signature
VALIDITY:
2 Years
D D M M Y Y Y Y
OrganisationName
Department
DOCUMENT PROOF (attested by Authorized Signatory of the Organization)
DGFT
Branch CodeIEC Code
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 RADate
TO BE FILLED BY RA OFFICE ONLY
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.
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.
(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
Authorized Signatory (Sign and Seal)
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 * * * * * *Copy of Import Export Certificate, in case of DGFT
Board Resolution Format
(On Company Letterhead)
CERTIFIED TRUE COPY OF RESOLUTION PASSED AT THE MEETING OF THE
BOARD OF DIRECTORS OF _____________________________________________
HELD ON _____________ AT ____________ A.M. AT THE REGISTERED OFFICE
OF THE COMPANY
=================================================================
Resolution No.1:
The board of directors passed the following resolutions unanimously.
“RESOLVED THAT the company has decided to obtain Class 3 Organisation DigitalSignature Certificate form the company approved by CCA.
Resolved further that _____________________, Director/Manager is authorised to apply forthe said Digital Signature certificate.
Resolved further that this shall continue until there is any change effected through aresolution passed by the Board of Directors.
(Director) (Director)
Certified True Copy
For ____________________________
Director
(Sign & Seal)
Letter of Identity Proof by Organization
(To be printed on organization letter head / Office seal. To be signed by HRD of Organization / Authorized
Signatory / Government Department in-charge. To be used if the Organizational ID card is not available for the
applicant.)
To:
eMudhra Limited
Bangalore
Subject: Organizational ID Proof of the applicant
Organization Name: _________________________________________________________________
Name of the Individual
Org ID Number (if available)
Designation
Department
I hereby confirm the Identity of the above Individual. I’m the Authorized Personnel to certify the
Identity on behalf of the Organization.
For the Organization,
(Seal & Signature)
Name: __________________________________
Designation: _____________________________