PND DIGISIGN 103, 1 st Floor, Simandhar, Wamanrao Sawant Road, Opp. Jana Seva Bank, Dahisar (E), Mumbai 400068. Tel: (022) 28284033 / 28282998 / 98209 44649 Email: pnddigisign@gmail.com website: www.pnddigisign.com INSTRUCTIONS / CHECKLIST 1.Please fill the form in BLOCK LETTERS & in BLUE INK ONLY 2.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: Attachments Document 1 Document 2 Document 3 Document 4 Note: Attested Copy of all documents according to your organisation structure as listed on last page. Organizational documents can be attested by Authorized signatory. Attestation in BLUE INK ONLY Attested Copy Applicant s PAN Card & Authorizing Person s PAN Card. [Attestation by the Gazetted Officer (List attached) / Bank Manager / Post Master), details of the attesting officer like designation, address and contact no. should also be mentioned. Signature of Attesting Officer in BLUE INK ONLY]. Authorisation Letter to be signed by Other Director / Partner & Seal on form Letter of Identity Proof by Organization in format attached with this form. Latest Photograph of the Applicant to be pasted and Signed across. 1. In case tax return is not submitted, the Organization should provide a selfaffidavit stating the reason. 2. In case, the organization name is different from that in PAN, the proof of name 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 be submitted 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 DIGISIGN 103, 1 st Floor, Simandhar, Wamanrao Sawant Road, Opp. Jana Seva Bank, Dahisar (E), Mumbai 400068. Tel: (022) 28284033 / 28282998 / 98209 44649 Email: pnddigisign@gmail.com website: www.pnddigisign.com List of Group A /Group B Gazetted officers Group A Gazetted officers include i) All India services though posted to states ii) Promotes from states to the cadre of Assistant commissioner and above iii) Police officers (Circle Inspector and above) iv) Additional District Civil surgeons v) Executive Engineers and above vi) District Medical Officer and above vii) Lt. Col and above viii) Principals of Government Colleges and above ix) Readers and above of Universities x) Patent Examiner etc. Group B Gazetted officers include i) Section Officer ii) BDO(Block Development Officer) iii) Tahsildar iv) Junior Doctors in Government Hospitals v) Assistant Executive Engineer vi) Lectures in Government colleges vii) Headmaster of Government high schools viii) 2nd Lieutenant to Major ix) Magistrate (Notary & SEO Attestation will not acceptable) Please make payment by Demand Draft in the favour of PND DIGISIGN or you can make payment by NEFT (Ask for Bank Details)and send the receipt of NEFT along with this form. COST STRUCTURE OF KIT AS FOLLOWS: TYPE DSC + SERVICE USB TOKEN DRIVERS/ SOFTWARE CD VALIDITY MRP FOR 2 YEAR KIT 3 2 Year 5000/- PAYMENT DETAILS Issue DD in favour of PND DIGISIGN Name of the applicant: DD No.: Dated Amount: for KIT Drawn on
APPLICATION FORM - SIGNATURE / ENCRYPTION CERTIFICATE FOR ORGANISATION (E) Application ID: (S) (For Office Use Only) PLEASE FILL IN BLOCK LETTERS ONLY. ALL FIELDS ARE MANDATORY More Instructions available at: http://www.e-mudhra.com/instruction.html APPLICANT INFORMATION L A S T N A M E Date of Birth F I R S T D DMMY Y YY N A M E Gender Male M I D D L E Female Affix recent passport size photograph of the applicant duly signed across N A M E Nationality Organisation Name Department CLASS: Org Address Class 1 Class 2 Class 3 Encryption Combo TYPE: City Pin code Signature State PAN of Applicant VALIDITY: Mobile 2 Years 1 Year Email ID DOCUMENT PROOF (attested by Authorized Signatory of the Organization) Organization Type: Company Partnership Proprietorship AOP/BOI Document Name LLP NGO/TRUST Company Partnership Proprietorship AOP/BOI LLP NGO/Trust Copy 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 DECLARATION BY APPLICANT AUTHORIZATION I 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 risks associated in case of Class 1 Certificate,when storing the private key on a device other than a FIPS 140-1/2 validated cryptographic module. I hereby authorize the above applicant, on behalf of our Organisation to apply for obtaining the Digital Signature/ Encryption Certificate issued by e-mudhra Date Signature of the applicant Place (As in ID proof Blue Ink Only) Authorized Signatory (Sign and Seal) TO BE FILLED BY RA OFFICE ONLY 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 hereby take full responsibility for any wrong verification made, or wrong documents submitted for the application. Date RA Name, Code & Seal Signature of RA 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 : info@e-mudhra.com Website: www.e-mudhra.com. Page 1 of 1 Version 2.8
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:
Board Resolution (Suggested format) (To be printed on organization letter head) CERTIFIED TRUE COPY OF THE RESOLUTION PASSED AT THE MEETING OF THE BOARD OF DIRECTORS OF (Company Name) HELD ON (Date) AT (Address) RESOLVED THAT the company has decided to authorize, Mr. / Ms. and is hereby authorized to sign and submit all the necessary papers, letters, forms, etc to be submitted by the company in connection with authorizing any of the personnel of the company (applicant) to procure Digital Certificate. The acts done and documents shall be binding on the company, until the same is withdrawn by giving written notice thereof. Specimen Signatures of Authorised Signatory: (Signature) RESOLVED FURTHER THAT, a copy of the above resolution duly certified as true by designated director / authorised signatory of the company be furnished to emudhra Limited and such other parties as may be required from time to time in connection with the above matter. For the Organization, (Seal & Signature) Name: Designation: