Digital Signature Application Form PDF

Digital Signature Certificate Subscription Form
Class 2 Individual Signing 1 Year

Class of Certificate Type of Certificate Certificate Validity
Class 3
With Encryption 2 Years
Org Name
Section 1: Subscriber Details
Name*:
Designation :
* Self Attested Photo
Date of Birth*: D D M M Y Y Y Y Gender *: Male Female
Address (Residential address in case of Individual or Organization address in case of DSC with ORG )
Organisation Name * :
(Mandatory in case of ORG DSC)
Door No/Building Name * :
Road/ Street/ Post Office * :
Town/ City/ District * :

State/ Union Territory * :
Country* : PIN Code*

Telephone Number* (with STD Code):
:
Mobile Number* :
Email id* :
Section 2: Identity Proof Details
Photo Identity Proof* Address Proof*

Identity Proof Name Address Proof Name
( Eg: Pan Card, DL, Passport, ...) ( Eg: Passport, DL, Latest
Telephone Bill, ...)
Identity Proof Number
Note*: Subscriber's signature should appear on the Photo ID Proof.

Section 3: Declaration
I hereby declare that all the information provided on this Subscription Form for the purpose of obtaining a digital certificate is true and correct to the best of
my knowledge. I am aware, as a subscriber for a digital signature certificate, the duties and responsibilities are applicable under the IT Act, India and the
SafeScrypt CA’s CPS https://www.safescrypt.com/pdf/cps.pdf .
Signature of the Subscriber*
Date*: D D M M Y Y Y Y Place*:
Note*: Subscriber has to sign before the Authorised LRA/Partner for Class3 DSC.
Section 4: Authorisation (*only for ORG DSC)
I , _______________________________________________________ acknowledge by my signature, that the Subscriber information in this document
is complete and accurate as per our office records. I fully understand that the Subscriber is responsible to transact on the Organisation’s behalf and I will
ensure timely revocation of Digital Signature Certificate in case the employee leaves the company in future.
Signature & Organisation seal*
For office use only

Attestation By Sify Authorised LRA/Partner(*For Class3 DSC Only)
I hereby declare that the subscriber has personally appeared before me and submitted the Partner Name:
original document copies of ID proof. I have verified the same with TRUE COPY.
Date of Issuance:
Signature and Seal *
Date * D D M M Y Y Y Y Name * City:

Note*: Safescrypt at its discretion, will make a telephone call to verify the details of the Subscriber.
SafeScrypt CA Services brought to you by:
Sify Technologies Limited, 2nd Floor, Tidel Park, #4 Rajiv Gandhi Salai, Taramani, Chennai - 600113. E-Mail: [email protected]

Instructions For Organisation (2B/3B) Digital Signature Applicants

1. Please ensure to use Correct Form and select the required Options for Class and Type of Digital Signature.

2. The Form should be completed legibly by the Applicant in his own handwriting in BLOCK Letters. There
should not be any overwriting. Application Form is available from our office or you can download it from
www.poddarprofessional.com else you may require it from us on your email. You can also use photocopy
of the attached Form for multiple requirements.

3. Recent Photo to be affixed on the Form and signed across.

4. Documents to be attached (All Signatures shall be with Rubber Stamp of the Organisation)
NOTE: All Documents including photo pasted on the Form to be Notorised
‐ Identity Proof of the Applicant ‐ (Any one as per List below)
‐ Address Proof of the Applicant ‐ (Any one as per List below)
‐ Organisation Existence Proof ‐ (Applicable documents as per List below)
‐ Organisation Address Proof ‐ (Any one as per List below)

Identity Proof of the Applicant Address Proof of the Applicant
(Any One) (Any One)
• Copy of Passport • Copy of Telephone Bill or Electricity Bill or
Water Bill (Not older than 3 months)
• Copy of Valid Driving License • Copy of Valid Passport or Driving License
or Voter ID Card
• Copy of PAN card • Copy of Gas Connection documents (Not
older than 3 months)
• Copy of Valid Post Office ID Card • Copy of Ration Card (Only if in English)
• Copy of Bank Account Passbook containing • Copy of Latest Bank Statements / Bank
the Photograph and attestation by the Bank Account Passbook
• Copy of Valid Government Employee photo ID • Copy of Property Tax / Corporation /
Card Municipal corporation receipt
• Copy of Any Other Government issued photo • Valid Post Office ID Card
ID card bearing the signature of the individual.

Organisation Existence Proof Organisation Address Proof
(As Applicable) (Any One)
In case of • Copy of Telephone Bill or Electricity Bill or
• Proprietorship : Valid Trade Licence + PAN Water Bill.
card of the proprietor or Sales Tax /VAT
Registration document (Document should • Copy of Latest Bank Statements.
reflect the owner as the proprietor)
• Partnership : Valid Trade Licence + Copy of
Partnership Deed + Partnership PAN Card. • Copy of Service Tax /VAT/Sales
• Company : Valid Trade Licence + Certificate Tax/NSIC/Professional Tax registration
of Incorporation + Company PAN Card. certificate.
• Others : Certificate of Registration, List of
Members of Governing Body, Resolution in
favour of Digital Signature Subscriber.

Payment can be made by CASH or AT PAR cheques / DD in favour of “Poddar Professional Solutions Private
Limited” or you can deposit / transfer to our Account. ICICI Bank Ltd., Howrah Branch, Current Account Number
628005009139, RTGS/NEFT/IFSC Code: ICIC0006280 (Zero, Zero, Zero, Six, Two, Eight, Zero).

Digital Signature Registration Authority
Poddar Professional Solutions Private Limited
Kolkata: 13, B. B. Ganguly Street, "Punar Nava Building" Gr. Floor, Kolkata 700012 (Near Lalbazar, Opp Himalaya Opticals) Ph : 033-40031162, 40085487
Howrah: 144, Narasingha Dutta Road, Howrah 711101, Fancy Market, Block 'A', 1st Floor,( Opp: Kadamtala Bus Stand ) Ph. 033-26435228, 9836900132
Dum Dum: 46, Manujendra Dutta Road, Kolkata – 700028, Uttarapan Market, 1st Floor, Rm No. 148, (Near Dum Dum PS) Ph 033-25500065, 9836900142
Phone : 9903022336. email : [email protected] URL: www.poddarprofessional.com

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Digital Signature Certificate Subscription Form

Class 2 Individual Signing 1 Year

Door No/Building Name * :

Road/ Street/ Post Office * :

Town/ City/ District * :

Country* : PIN Code*

Section 2: Identity Proof Details

Photo Identity Proof* Address Proof*

Note*: Subscriber's signature should appear on the Photo ID Proof.

Signature of the Subscriber*

Signature & Organisation seal*

For office use only

Date * D D M M Y Y Y Y Name * City:

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