Male Female NationalityDate of Birth Gender

City

State

Pin code

MobilePAN

DECLARATIONI 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 INFORMATIONAffix 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 2.9

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 6740 1400 Fax : +91 80 4227 5306. Email : info@e-Mudhra.com 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)

ApplicantName

Aadhaar

Aadhaar Card of applicant (Mandatory if Aadhaar provided)

(NOTE : Either PAN and / or Aadhaar No. is mandatory)

Aadhaar Details

3 Years

Instructions:

1. All Details given in application form must be matched with supporting documents. 2. Application form must be duly signed by applicant and signature should be same as in photo ID

provided by applicant. 3. Don’t make any alteration in Application Form, if found, will lead to rejection.

4. Attach the supporting documents as per list provided in application form only and should be valid as per

instruction given in application form. 5. Copy of supporting documents must be visible and readable.

6. Supporting documents must be attested by Gazetted Officer OR Bank Manager OR Post Master

for verification and attestation.

7. In case of PAN Based DSC, provide photo copy of Pan Card. Print of online PAN data/ Details is not accepted.

8. In Case of Organization Users, Authorization Letter must be on Organization’s Original Letter Head with

Address provided in application form if organizational/Departmental ID card not issued to Authorized

Signatory.

9. Minimum Requirement for using Digital Signature is: Internet Explorer 7/ Mozilla Firefox or above

with OS Windows 7 /Windows 8/ Windows 10. We don’t have any support for old windows OS or Mac OS.

10. All signature should be with blue pen only.

11. Before sending any hard copy of application form and supporting document send it’s complete scan copy

to our mail address- ajenterprises.dun@gmail.com for document should

Undertaking by Applicant for Digital Signature Certificate - Name of Applicant For Office Use ONLY (Application ID)

____________________________________________

Terms & Conditions:

• Rate may be varying time to time. In case any changes we will make you aware of that in advance through telephonically or by e-mails.

• If the certificate get corrupted or some hardware problem raised after providing in Tested - OK condition applicant will have to pay for certificate

or for whole including USB token charges.

• In case any assistance required for Installation telephonically/physically as required on the place, we shall provide the support.

• Any problem arises in downloading the DSCs certificate by the side of applicant like system failure, internet problem, and Internet browser setting,

he/she is the responsible, and we are unable to serve in that case.

• DSC request Forms may be collected by the department/Organization but in that case department will have to pay Rs. 50 Extra (convenience Charges) ,

or you have to submit/ receive all the DSC request form/ DSCs to/from our collection center specified by the company that will communicated to you

later.

• More than distance in range of 5-10 Km in Dehradun, you will have to submit/receive DSC request Form/DSCs by hand or by currier.

• If any distant person/officers want DSC by currier service/ speed-post that are also available. You can ask for it, charges are applicable that may vary on

locations.

• All the application forms collected by department will again verified by our RA/RA’s Designated officers through Phone or physically or other means.

• You can pay us online payment through NEFT or RTGS, but keep the acknowledgement of the transactions details and provide us soft copy or the

printout of that record during providing the DSC request forms. After verifying the successful paid amount, we will further send your request form for

issuing DSCs.

• All the documents of the department person/officers should be verified by department/ organization head, and he is the solely responsible person

against that officer’s/person’s for any discrepancies arise.

• For any System/Online Applications under developing status or before successfully pass the testing condition at the user end we are not responsible.

Our DSCs are successfully working under most of Govt. / prestigious Organization’s applications.

• Minimum Processing Time to issue DSC would be 24 - 72 working hours (excluding Sundays, Public Holidays, and working hours of the day on which

form is submitted).

• If the requirements are on urgent basis cost will increase in Rs. 300.00 (completion time for urgent cases are 2- 3 day that is depend on the completed

form, supporting document and fee received to our person. Normal completion to ready the DSC is 5-7 Day.)

• All forms are subject to acceptance / rejection by eMudhra.

• If Application form is rejected by eMudhra, the rejected forms would remain with eMudhra and Applicant need to submit a fresh Application form

with all required attested document again within 48 hours after rejection by eMudhra. If applicant fails, No Refund would be entertained. If Applicant

reacts after 48 Hour, Applicant need to submit Fee and Form again.

• Check your Digital Signature Certificate within 24 hours from issuance. After that we shall not be responsible for any type of mistake in DSC issuance.

• Issuance of DSC doesn’t mean or provide any type of guarantee to get done / finish your work.

• Don’t make any alteration in Application Form, if found, will lead to rejection.

• You may also pay us through Demand Draft in favor of A & J Enterprises payable at Dehradun.

• In case of urgent, you may pay us also in form of cash, you will receive invoice at time of DSC receiving.

I have read and understood all the above instructions, terms and conditions and hereby agreed to abide.

(Signature of Applicant)

Undertaking for Assistance / Help to download & provide the Digital Signature Certificate

I __________________________________________________ (Applicant Name) don’t have knowledge to Download my Digital Signature Certificate, so I need help / assistance from Digital Signature Provider (Vendor) to download & provide my Digital Signature Certificate. Now I hereby requesting & giving my undertaking to DSC provider to Download & provide my Digital Signature Certificate to me.

(Signature of Applicant)

Signing Certificate

Encryption Certificate

Letter Head of Organization

Letter from Organization To

eMudhra Limited Bangalore

Subject: Organizational ID Proof For Applicant

I hereby confirm the Identity of Mr. /Mrs. ________________________ (Applicant Name)

working in _________________________ (Organization Name) since _________ (start day of

working within organization).

Other Details:-

Designation Applicant Photograph

Department Affix Applicant’s Passport- size photograph and signed across

Office Contact No.

Email

(Applicant’s Signature ) (Authorized Signatory Seal & Signature) ___________________ _______________________ (Optional For Proprietary Form)

Letter Head of Organization

Declaration

To

eMudhra Limited Bangalore

Subject: Organizational ID Proof of the Authorized Signatory

I hereby confirm the Identity of Mr. /Mrs. ________________________ (Authorized

Signatory Name) working in _________________________ (Organization Name) since

_________ (start day of working within organization). I’m the Authorized Personnel to certify

the Identity on behalf of the Organization.

Other Details of Authorized Signatory:-

Designation

Department

Office Contact No.

Email

(Authorized Signatory Seal & Signature )

Signature: _______________________

Seal: _______________________