Schedule4 – THE INFORMATION TECHNOLOGY (CERTIFYING AUTHORITIES) RULES,2000

SCHEDULE-IV

[See rule 23]

Form for Application for issue of Digital Signature Certificate

for Individual/Hindu Undivided Family Applicant

1. Full Name * [Name of the Karta in case of Hindu Undivided Family]

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

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. ___________________________________

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. In case of foreign national, visa details __________________________________

10. Credit Card Details

Credit Card Type ___________________________________

Credit Card No. ___________________________________

Issued By ___________________________________

11. E-mail Address ___________________________________

12. Web URL address ___________________________________

13. Passport Details #

Passport No. ___________________________________

Passport issuing authority ___________________________________

Passport expiry date ___________________________________

14. Voter’s Identity Card No. # ___________________________________

15. Income Tax PAN no. # ___________________________________

16. ISP Details

ISP Name * ___________________________________

ISP’s Website Address, if any ___________________________________

Your User Name at ISP, if any ___________________________________

17. Personal Web page URL, if any ___________________________________

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, if any ___________________________________

No. of Branches ___________________________________

Nature of Business ___________________________________

       ___________________________________

       ___________________________________

       ___________________________________

21. Income Tax PAN No.* ___________________________________

22. Turnover in the last financial year Rs. ________________________________

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

Details of Partners/Members/Directors

No. of Partners/Members/Directors ___________________________________

Full Name

Last Name/Surname __________________________________

First Name ___________________________________

Middle Name ___________________________________

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. ___________________________________

Nationality ________________________________

In case of foreign national, Visa details_______________________________

Passport Details #

Passport No. ___________________________________

Passport issuing authority ___________________________________

Passport expiry date ___________________________________

Voter’s Identity Card No. # ___________________________________

Income Tax PAN no. # ___________________________________

E-mail Address ___________________________________

Personal Web page URL, if any ___________________________________

For Government Organizations/Agencies

24. Particulars of Organization/Agency : *

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. ___________________________________

Name of the Head of Organization ___________________________________

Designation ___________________________________

E-mail Address ___________________________________

25. Bank Details

Bank Name * ___________________________________

Branch * ___________________________________

Bank Account No. * ___________________________________

Type of Bank Account * ___________________________________

26. Type of Digital Signature Certificate required * ___________________________

27. Any other detail ___________________________________

Date Signature of the Applicant

___________________________________________________________________

Instructions : 1. Columns marked with * are mandatory as applicable.

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 applicants.

4. Column No. 18 to 23 are to be filled up if applicant is a Company/ Firm/ Body of Individuals/ Association of Persons/ Local Authority.

5. Column No. 24 is to be filled up if applicant is a Government organization.

6. Column No. 25 & 26 are to be filled up by all applicants.

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