J~ •• ".-: ~'~I§GNFC

Registration Form for Digital CertificateGOVERNMENT

(n)CodeSolutions

Customer Identification Number: _

~~~S~TIC~ ~~. ;~E I Class2

(for office use only)

OR Class3

Validity 2 Years Validity 1 Year Only SigningOR OR Sign & Encl)'pt

INSTRUCTIONS;

1. Please fill the form in English only in legible format and INBLUE INK ONLY.

2..OlD would be as per our CPS. Please refer to our CPS atW'hw.ncodeso[utions.comlcps.pdf for more mformation.

3. Incase of keypair been compromisedllosl,ldele!ed, pleaseapply for revocation of certificate.

4. For obtaining Class 3 ·Video recording of DSC applicant" ismandatory as per CCA- Guidelines.

5. Incomplete application is liable for RejectIOn The rejected form wouldbe physically discarded after 15 days from the date of rejection. Norequesl would be entertained with respect to rejected farm after therejection period.

6. All supporting documents should be attested by Gazetted Officer orBank Manager or Post Master and the Name, designation, officeaddress and contact number of the attesting officer should be clearly'/isibte.

7. FIPS 140-112 level validated Hardware cryptographic token required todownload the DSC.

III...Applies nt Name APPLICANT TO SIGN ACROSS THE PHOTOGRAPH EXTENDED TO APPLlCATlOP! FORM

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Identity Details of Applicant DOC No.

[J "PAN rJ Drivillg 0 Passport 0 Govt. [,-1 Postoffice r] Copy of Bank Account Passbook containing photo & signod byCard License 10 Card .-~ 10 Card .._.. appllcant with attestation by concerned Bank 0 ricer

Tick anyone and enclose the attested copy of same. ("'For PAN based OSC, please provide the PAN Card deraus.)- -

Organization Name

Go'lt. 10 Card Detail{Enclose attested copy)

.•. Office Address

Area Il.andmark

PLEASE NOTE:"Section 71 of IT Act stipulates that if anyone makes a mlsrepresentanon or suppresses any marenat fact from the CCA or CA for olllfunlO9 any DSCsuch person shall be punishable with unpnsonmen up to 2 years or With fine up to one lakh rupees or with both.

DECLARATION:1. In case of submission of Aaonaar Card Details. I provide m)' consent to (n)Code Solutions for using Aaenaar Card detailS For my identity

aull1enlicatiol1 only.

2. I hereby agree that I have read and understood {n)Code Solutions CPS and the subscriber agreement and promise to alJid€ the same. I haveread and understood guidelines for storage 01private keys mentioned in (n)Code Solutions CPS.

3. I herehy authorise (n)Code Solutions to conduct mobile verification as per CCA guidelines, on the number menli.oned above.

Date: Place:

Verified by (n)Code Office For RAu$e only

All Documents, address and physical presence wnf1cd by

Seal & Signature RA Name, Seal & Signature

V 4.4Toll Free: 1800- 233 - 1010

www.ncodesotutlons.ccm (n)Page tt 1·2

•.. - ,.A. !:I ~.~,GNFC

Registration Form for Digital CertificateGOVERNMENT

(n)CodeSolutions

Customer Identification Number: _ (for office use only)

Attested copy of following for

Government Application

A. Applicant's identity card.

B. The application for DSC should be forwarded/Certified by the authorized signatory (Competent autnort y of the Department! Head ofOffice I NIC Coordinator.

C. Copy of identity card of authorised signatory.

Note:

! A. For Class 3 certificate, HOD should. certify the physical verification of subscriber. with a statement similar to tlJat used for life certificateof pensioners

B. The attestation of documents may be carried out by Head of the Office/Gazetted Officer.

III... PAYMENT DETAILS

Date: Amount:Bank Name: DO I Cheque No. :

Authorization Letter }t===============To,(n)Code Solutions (A DiviSion of GNFC Ltd.)This to certifiy thatMr. I Ms. (certificate applicant)

Moblle has provided correct information in the appllcatlon forrn for issue of Digital Certificate to the bestof my knowtedge and belief and is working with (organization name). Icertify the physical verification of the

applicant, He I She is hereby authorized to obtain a Digital Certificate issued by (n)Code Solutions.

DETAILS OF AUTHORISING PERSON .

Name

Designation [- -- --~=~~.=~=~~~:~~~~~=~~~]Identity L_.. ._~~~~~=:-.=~=~===~.····--·-····-····~..JDate SiSll3turl> of Auth6Yl!Hrlg Pl)r&on (Bluo Ink Ollly)

(wllh bll'llll c>t Organ17of1Uol1;

Place [Sign:

(n)Code Offices Corporate Office Ahmedabad: 079-4000 7300 • dscsales@llcode.in

Delhi011-26452279180northsales@ncode.in

Bangalore080-25272525soutIJsales@ncode.in

Mumbai022-22048908mumbaisales@ncode-in

surat0261-2789944suratsales@ncode.tn

V 4.4 Toll Free' 1800 - 233 -1010 ( )·www.ncodeSolutlons.com n

Corporate Office· . (n)Code Solutions, 301, GNf-C lnfo!ower. Bodakdev. Ahmlldabad-380054Page II 2· 2