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. Fathers 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. Voters Identity Card No. # ___________________________________
14. Income Tax PAN no. # ___________________________________
15. ISP Details
ISP Name * ___________________________________
ISPs 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. Voters 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:
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.
