PND DIGISIGNpnddigisign.com/emudhra_Class3_Indvl.pdf · Mobile Number. 7. Video recording to ......
3
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: [email protected] 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 An attested copy of PAN Card If PAN Card is not available, submit Copy of Latest Income Tax Return along with Photo Identity proof as listed on last page of the form. Signature & Photo should be clearly visible on PAN Card or any other Identity Proof. Document 2 An attested copy of proof of address any one from listed on last page. In case of any utility bills like electricity, water, gas, and telephone bill, & Bank Statement should not be older than 3 months from the date of application. [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]. Latest Photograph of the Applicant to be pasted and Signed across. 4. Unique Email Address & Mobile Number are 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. 7. Video recording to be done as per guidelines issued by eMudhra.
Transcript of PND DIGISIGNpnddigisign.com/emudhra_Class3_Indvl.pdf · Mobile Number. 7. Video recording to ......
PND DIGISIGN103, 1st Floor, Simandhar, Wamanrao Sawant Road, Opp. Jana Seva Bank, Dahisar (E), Mumbai – 400068.
Tel: (022) 28284033 / 28282998 / 98209 44649 Email: [email protected] website: www.pnddigisign.com
INSTRUCTIONS / CHECKLIST1. 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:
AttachmentsDocument 1 An attested copy of PAN Card If PAN Card is not available, submit Copy of
Latest Income Tax Return along with Photo Identity proof as listed on last page ofthe form. Signature & Photo should be clearly visible on PAN Card or any otherIdentity Proof.
Document 2 An attested copy of proof of address any one from listed on last page.In case of any utility bills like electricity, water, gas, and telephone bill, & BankStatement should not be older than 3 months from the date of application.
[Attestation by the Gazetted Officer (List attached) / Bank Manager / PostMaster), details of the attesting officer like designation, address and contact no. shouldalso be mentioned. Signature of Attesting Officer in BLUE INK ONLY].Latest Photograph of the Applicant to be pasted and Signed across.
4. Unique Email Address & Mobile Number are 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 willbe 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 ApplicantsMobile Number.
7. Video recording to 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: [email protected] 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 paymentby NEFT (Ask for Bank Details) and send the receipt of NEFT along with this form.
COST STRUCTURE OF KIT AS FOLLOWS:
TYPE DSC +SERVICE
USBTOKEN
(ePass 2003)
USBTOKEN
(ALLADIN)
DRIVERS/SOFTWARE
CD
MRP(2 YEAR
VALIDITY)
KIT 3 √ √ √ 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
DECLARATION
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.
Date
Place Seal & Stamp (If any) 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 INDIVIDUAL
PLEASE FILL IN BLOCK LETTERS ONLY. ALL FIELDS ARE MANDATORY
Page 1 of 1 Version 2.8
Date
Address
Email ID
More Instructions available at: http://www.e-mudhra.com/instruction.html
1 Year
Class 1 Class 2 Class 3
Signature Encryption Combo
CLASS:
TYPE:
VALIDITY:
2 Years
TO BE FILLED BY RA OFFICE ONLY
D D M M Y Y Y Y
DOCUMENT PROOF (attested by Bank Manager OR Post Master OR Gazetted Officer (Group ‘A’ /Group ‘B’) , against producing the originals)
Proof of Identity (Any one of below)* Proof of Address (Any one of below)*
AADHAAR Card.
Voter ID Card.
Driving License (DL)/ Registration certificate (RC).
Passport.
Telephone Bill (Not older than 3 Months)
Water Bill (Not older than 3 Months).
Gas Connection/Bill (Not older than 3 Months).
Electricity Bill (Not older than 3 Months).
Bank Statements signed by the bank (Not older than 3 Months).
Service Tax/VAT Tax/Sales Tax registration certificate.
Property Tax/ Corporation/ Municipal Corporation Receipt.
Passport.
PAN Card of applicant (Mandatory if PAN provided)
Driving License.
Post Office ID Card.
Bank Account Passbook containing the photograph and signed by an individual withattestation by the concerned Bank official.
ID Number
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 : [email protected] Website: www.e-Mudhra.com.
Photo ID card issued by the Ministry of Home Affairs of Centre/State Governments
Any Government issued photo ID card bearing the signatures of the individual.
Attesting Officer *Self attested copy of ID Card/Contact details of attesting officer.
(Having applicant photo and Signature, as part of it)
(As in ID proof | Blue Ink 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 herebytake full responsibility for any wrong verification made, or wrong documents submitted for the application.
Application ID: (S) (E) (For Office Use Only)
