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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