Schedule1 – THE INFORMATION TECHNOLOGY (CERTIFYING AUTHORITIES) RULES,2000

SCHEDULE-I

[See rule 10]

Form for Application for grant of License to be a Certifying Authority

For Individual

1. Full Name *

Last Name/Surname __________________________________

First Name ___________________________________

Middle Name ___________________________________

2. Have you ever been known by any other name? If Yes,

Last Name/Surname __________________________________

First Name ___________________________________

Middle Name ___________________________________

3. Address

A. Residential Address *

Flat/Door/Block No. ___________________________________

Name of Premises/Building/Village ___________________________________

Road/Street/Lane/Post Office ___________________________________

Area/Locality/Taluka/Sub-Division ___________________________________

Town/City/District ___________________________________

State/Union Territory __________________

Pin : __________

Telephone No. ___________________________________

Fax ___________________________________

Mobile Phone No. ___________________________________

B. Office Address *

Name of Office ___________________________________

Flat/Door/Block No. ___________________________________

Name of Premises/Building/Village ___________________________________

Road/Street/Lane/Post Office ___________________________________

Area/Locality/Taluka/Sub-Division ___________________________________

Town/City/District ___________________________________

State/Union Territory __________________ Pin : __________

Telephone No. ___________________________________

Fax ___________________________________

4. Address for Communication * Tick  as applicable A or B

5. Father’s Name *

Last Name/Surname __________________________________

First Name ___________________________________

Middle Name ___________________________________

6. Sex * (For Individual Applicant only) Tick  as applicable : Male / Female

7. Date of Birth (dd/mm/yyyy) * –/–/—-

8. Nationality * ___________________________________

9. Credit Card Details

Credit Card Type ___________________________________

Credit Card No. ___________________________________

Issued By ___________________________________

10. E-mail Address ___________________________________

11. Web URL address ___________________________________

12. Passport Details #

Passport No. ___________________________________

Passport issuing authority ___________________________________

Passport expiry date (dd/mm/yyyy) –/–/—-

13. Voter’s Identity Card No. # ___________________________________

14. Income Tax PAN no. # ___________________________________

15. ISP Details

ISP Name * ___________________________________

ISP’s Website Address, if any ___________________________________

Your User Name at ISP, if any ___________________________________

16. Personal Web page URL address, if any ___________________________________

17. Capital in the business or profession * Rs. ________________________________

(Attach documentary proof)

For Company /Firm/Body of Individuals/Association of Persons/ Local Authority

18. Registration Number * ___________________________________

19. Date of Incorporation/Agreement/Partnership * –/–/—-

20. Particulars of Business, if any: *

Head Office ___________________________________

Name of Office ___________________________________

Flat/Door/Block No. ___________________________________

Name of Premises/Building/Village ___________________________________

Road/Street/Lane/Post Office ___________________________________

Area/Locality/Taluka/Sub-Division ___________________________________

Town/City/District ______________________ Pin _________

State/Union Territory ___________________________________

Telephone No. ___________________________________

Fax ___________________________________

Web page URL address, if any ___________________________________

No. of Branches ___________________________________

Nature of Business ___________________________________

      ___________________________________

21. Income Tax PAN No.* ___________________________________

22. Turnover in the last financial year Rs. ________________________________

23. Net worth * Rs. ________________________________

(Attach documentary proof)

24. Paid up Capital * Rs. ________________________________

(Attach documentary proof)

25. Insurance Details

Insurance Policy No.* ___________________________________

Insurer Company * ___________________________________

26. Names, Addresses etc. of Partners/Members/Directors (For Information about more persons, please add separate sheet(s) in the format given in the next page) *

No. of Partners/Members/Directors ___________________________________

Details of Partners/Members/Directors

A. Full Name

Last Name/Surname __________________________________

First Name ___________________________________

Middle Name ___________________________________

B. Address

Flat/Door/Block No. ________________________________

Name of Premises/Building/Village ________________________________

Road/Street/Lane/Post Office ________________________________

Area/Locality/Taluka/Sub-Division ________________________________

Town/City/District ________________________________

State/Union Territory Pin ________________________________

Telephone No. ________________________________

Fax No. ________________________________

Mobile Phone No. ________________________________

C. Nationality ________________________________

In case of foreign national, Visa details_______________________________

D. Passport Details #

Passport No. ___________________________________

Passport issuing authority ___________________________________

Passport expiry date ___________________________________

E. Voter’s Identity Card No. # ___________________________________

F. Income Tax PAN no. # ___________________________________

G. E-mail Address ___________________________________

H. Personal Web page URL, if any ___________________________________

27. Authorized Representative *

Name ___________________________________

Flat/Door/Block No. ___________________________________

Name of Premises/Building/Village ___________________________________

Road/Street/Lane/Post Office ___________________________________

Area/Locality/Taluka/Sub-Division ___________________________________

Town/City/District ___________________ Pin ____________

State/Union Territory ________
___________________________

Telephone No. ___________________________________

Fax ___________________________________

Nature of Business ___________________________________

For Government Ministry/Department/Agency/Authority

28. Particulars of Organization: *

Name of Organization ___________________________________

Administrative Ministry/Department ___________________________________

Under State/Central Government ___________________________________

Flat/Door/Block No. ___________________________________

Name of Premises/Building/Village ___________________________________

Road/Street/Lane/Post Office ___________________________________

Area/Locality/Taluka/Sub-Division ___________________________________

Town/City/District ____________________ Pin __________

State/Union Territory ___________________________________

Telephone No. ___________________________________

Fax No. ___________________________________

Web page URL Address ___________________________________

Name of the Head of Organization ___________________________________

Designation ___________________________________

E-mail Address ___________________________________

29. Bank Details

Bank Name * ___________________________________

Branch * ___________________________________

Bank Account No. * ___________________________________

Type of Bank Account * ___________________________________

30. Whether bank draft/pay order for license fee enclosed * : Y / N If yes,

Name of Bank ________________________________

Draft/pay order No. ________________________________

Date of Issue ________________________________

Amount ________________________________

31. Location of facility in India for generation of Digital Signature Certificate *

________________________________

32. Public Key @________________________________

33. Whether undertaking for Bank Guarantee/Performance Bond attached * : Y / N

(Not applicable if the applicant is a Government Ministry/Department/Agency/ Authority)

34. Whether Certification Practice Statement is enclosed * : Y / N

35. Whether certified copies of business registration document are enclosed : Y / N

(For Company/ Firm/ Body of Individuals/ Association of Persons/ Local Authority)

If yes, the documents attached:

    1. …………………………

    2. …………………………

    3. …………………………

36. Any other information _________________________________

_________________________________

_________________________________

 

Date Signature of the Applicant

___________________________________________________________________

Instructions : 1. Columns marked with * are mandatory.

2. For the columns marked with #, details for at least one is mandatory.

3. Column No. 1 to 17 are to be filled up by individual applicant.

1. Column No. 18 to 27 are to be filled up if applicant is a Company/ Firm/ Body of Individuals/ Association of Persons/ Local Authority.

2. Column No. 28 is to be filled up if applicant is a Government organization.

3. Column No. , 29, 30, 31 and 34 are to be filled up by all applicants.

4.  @ Column No. 32 is applicable only for application for renewal of license.

5. Column No. 33 is not applicable if the applicant is a Government organization.

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