PND DIGISIGN103, 1st 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 ONLY2.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:

AttachmentsDocument 1 Attested Copy of all documents according to your organisation structure as listed on last

page. Organizational documents can be attested by Authorized signatory. Attestation inBLUE INK ONLY

Document 2 Attested Copy Applicant’s PAN Card & Authorizing Person’s PAN Card. [Attestationby the Gazetted Officer (List attached) / Bank Manager / Post Master), details ofthe attesting officer like designation, address and contact no. should also be mentioned.Signature of Attesting Officer in BLUE INK ONLY].

Document 3 Authorisation Letter to be signed by Other Director / Partner & Seal on form

Document 4 Letter of Identity Proof by Organization in format attached with this form.

Latest Photograph of the Applicant to be pasted and Signed across.

Note: 1. In case tax return is not submitted, the Organization should provide a self-affidavit stating the reason.

2. In case, the organization name is different from that in PAN, the proof ofname 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 besubmitted 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 DIGISIGN103, 1st 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 includei) All India services though posted to statesii) Promotes from states to the cadre of Assistant

commissioner and aboveiii) Police officers (Circle Inspector and above)iv) Additional District Civil surgeonsv) Executive Engineers and abovevi) District Medical Officer and abovevii) Lt. Col and aboveviii) Principals of Government Colleges and aboveix) Readers and above of Universitiesx) Patent Examiner etc.

Group ‘B’ Gazetted officers includei) Section Officerii) BDO(Block Development Officer)iii) Tahsildariv) Junior Doctors in Government Hospitalsv) Assistant Executive Engineervi) Lectures in Government collegesvii) Headmaster of Government high schoolsviii) 2nd Lieutenant to Majorix) Magistrate

(Notary & SEO Attestation will not acceptable)

Please make payment by Demand Draft in the favour of “PND DIGISIGN” or you can make payment byNEFT (Ask for Bank Details) and send the receipt of NEFT along with this form.

COST STRUCTURE OF KIT AS FOLLOWS:

TYPE DSC +SERVICE

USBTOKEN

DRIVERS/SOFTWARECD

VALIDITY MRPFOR 2YEAR

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 ______________________________________________________________

Male Female Nationality

L A S T N A M E

Date of Birth Gender

City

State

Pin code

MobilePAN of Applicant

DECLARATION BY APPLICANTI 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 risksassociated in case of Class 1 Certificate,when storing the private key on a device other than a FIPS 140-1/2 validated cryptographic module.

Date

Place Signature of the applicant

RA Name, Code & Seal Signature of RA

APPLICANT INFORMATION F I R S T N A M E M I D D L E N A M E Affix recent passport

size photograph of the applicant duly

signed across

APPLICATION FORM - SIGNATURE / ENCRYPTION CERTIFICATE

FOR ORGANISATION

PLEASE FILL IN BLOCK LETTERS ONLY. ALL FIELDS ARE MANDATORY

Page 1 of 1 Version 2.8

Date

Org Address

Email ID

More Instructions available at: http://www.e-mudhra.com/instruction.html

1 Year

Signature Encryption Combo

CLASS:

TYPE:

VALIDITY:

2 Years

TO BE FILLED BY RA OFFICE ONLY

D D M M Y Y Y Y

OrganisationName

Department

DOCUMENT PROOF (attested by Authorized Signatory of the Organization)

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.

(As in ID proof | Blue Ink Only)

AUTHORIZATIONI hereby authorize the above applicant, on behalf of our

Organisation to apply for obtaining the Digital Signature/ Encryption Certificate issued by e-Mudhra

Class 1 Class 2 Class 3

Authorized Signatory (Sign and Seal)

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 herebytake full responsibility for any wrong verification made, or wrong documents submitted for the application.

Organization Type: Company Partnership Proprietorship AOP/BOI LLP NGO/TRUST

Document Name Company Partnership Proprietorship AOP/BOI LLP NGO/TrustCopy 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 * * * * * *

Application ID: (S) (E) (For Office Use Only)

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: _____________________________