Registration Form for Digital Certificate n)Code

GOVERNMENT Solutions
Customer Identification Number: (for office use only)

PLEASE TICK ANY ONE Class2 OR Class3

Validity 2 Years OR Validity 1 Year Only Signing OR Sign & Encrypt

1, P ~ "'" " I tre , - rn i E ;;I !lI'I Of! Y I' f=i;llj: " iO'JTIal. 5. llel c.Jllon " !I1l_" fN =
jec: ._n Tr rtl)ec.led 'Qr11 '"c <.. be
CJ lld . terde,j ·.lfte-r 1'St! o f -:: ·rom t t'Qtl!"!"' rfe·ec :iI'. ·, o r!' I' j ~!·.\l ,j lJ l.j
2, Fe jl,: ::; r ' Ir .",r:,cn _r.di ;] ~n 31",1 ':ide", reer i 1;; c,'
rl as f.-r C C. be e', -rt~ e el "" ,.h r.::!ope'- - ~ ~leC:cIl fo ,." tier ill" re-liH." ; ' r ,:"nOd
I/) D~ .l~pl ~ -rnmdcl - (;.u ; 11- - •
z 6, 01 :' 'A'Q.IU be er OU' PS :llea e re'er to (ur ~ PS III WV. N I" C :l,,{' :. ltJ!l'~ r ~ .
o (I:')

I­ CO:I -nJC~ P4r f 'lr "tor" rforri Jt 0 1.

tJ
::J 7, I r c :r~ of k YP JIT Leen CO 'll prom sedno!l'/delo;lecI : ea~1!' (lOpl,' '0' re 'ocalJOn
II:
l­ o( ce rtt" cat=
II)
Z B, U.... B C r /;I:l to ell re ;)l.lf to ,j Om-le DSC J :') per CCA ;!uloellne">
~.. ',~I e 1 f S~ 1 II n~ . COlT\. P'J =: ( ::-.-- CR F TO df

Applic3nt N3m& APPlI(ANT TO SIGN A(ROSS THE PHOTOGRAPH EXTHJDED TO APPlI(ATION FORM ~

2 Unique Email 10

3 Unique Mobile No,

I !
4

o
GST Number

Idenl1ty Delai ls of Applicant DOC No.

*PAN Card or 0 Driving 0 Poss~ort 0

I I
I I
Go,!,
=I
0
J
Posto!f. cc 0
=:
I [ 1
III
Copy of Bank Ac::oJI~t Passbook contail i"9 photo &~ ' 9n{:d by
*AoJ<lila'lI N.lln bo( Lic(;f)sC 10 Cord ID Card o.ppllCOl1t ~.1 !11 atulStallon by con co m c ann" orr,ccr
LI I hereby declare thllt nelthor PAN nor AadhQar NlImber has beon ISSlIC'.l to , 1C
"For PAN based DSC , pis provide the PAN Card details and enclos.e the attostod copy of s:tme.

6 Org;JOIz:ltion N:lme [

7 Org;lniz;!tion;J1 Em;lillD I~==========~~~~========~~~==~

Govt, 10 C:II d Oet;Jil :==:;;:::::=::;==::;==;:==;::r-======;:::=::;:==;--­
8
(Enclose attested copy) LI oep:utm e
__n_t ---============-===~
9 Office Add ress

10 Ar&a I Landmark L - -_ _ _ _ " - - - -_ _ ~_JlI ___

PLEASE NOTE:
3 ec tton 71 of I ct \WWWJlCOdesolutions.oomJPOFllTblll2000.J)d1) stIpulates h if 3nyone makes ;] Isreprese lallen or sup res as a y m erfal
r,J,: t frol th e CC or GA f Obtl in ng ::UW DSC sud'! oerson shall 00 p nlshlll),e 'iith impnsonment up ill years or With fine up to one 11k ruoees
(I with noth.
DECLARATION:
1, In case of su mission r . ;adhsar Ca rd Deta is. I provide m consent to o)eO<! Solu cns for using Aadham Card details for Klentlty
authenu '11)0 only
2, I he reby agree that I h .... e rea a d underSTood (n)CO<!e SolutIons CPS and :he subscriber agreement and promtse 0 ahide ti>e same 1 hav
read d understood guideline" for slo 9 of private eys enuOllw In {n)Code SolutiOns CPS
3, I ereby 3uthonse (n)Code SolUIions ! cond uct mobile ertfirntio as per CC Q idel nes, on the ,1umber mentIOned above .
4. 1. A:ldhaJr older herebYIlTOvlde my co nsent o (n)Cotle Solu ns aCert i gAUtl1 rfty ( r hroug h lhel r eglsntiOn utMri , )andSlltm : .;
P.1p r l.asEd COp,1of IlW Aadhfl3f Card ,s supporting document for lssuance of Olgl1a Signa! r Certl l(ale 3S per IT Act
Signature of Applicant

Dale : Place: with .eal of OrganizAtion

V.riri. d by (n)Code Offlc. For RA us. only

Se al & Signature RA Name, Seal & Signature

V 5.1
Toll Free: 1800-419-4455

www.ncodesolutions.com
(n)
Pa; e ,: , . 4 Corporate Office: 14 th Floor. Tower One, Road 5C. Zone 5, Guj ara t Internatlon I A nn nce Tech City (G IFT City}, Gand inaga r - 382 35t> .
 Registration Form for Digital Certificate (n)Code
GOVERNMENT Solutions
Customer Identification Number: _ _ _ _ _ _ _ _ _ _ _ _ (for office use only)

f Documents Required for verifiCati0iO:} (,

Attested copy of following for

Government Application

A. A~pl i c~w\"s iden ity card.

B. The :lpplication for DSC should he forwardediCer .ified by t, e au r.horize1 signatory (Co ~peten ( aU .horiiY of !t',e Departm8ntl ead I}

Office i NIC Coordinator.

C . Copy of identity c:lrd of authorised signa:ory.

Note:
A. For Class 3 cer.ificate, HOD should certify tile physical .... erificJ !i(ln of subscriber. wi:h J statement similar .0 that used for life- certiric:l!e
of pensioners
B. The a testation of documents may be carried out by Head of the Office/Gazetted Officer.

PAYMENT DETAILS

Dalo : Bank Name: DD / Cheque No. A 101Inl :

Authorization Letter
To,

.. (n)Code Solutions (A Division of GNFC Ltd.)

This to certifiy that

Mobile h. . provllHld correct infonmation in the application fonm for issue of Digital Certificate to the best
of my knowledge and beliof and 18 working with (organization name). I certify the phy"Sical verification of the
applicant. He I She Is hereby authof"ized to obtain 8 Digital Certificate Issued by (n)Code Solutions.

DETAILS OF AUTHORISING PERSON

N.. me I
DeSignation I
-===================~,
! Identity
F====================- -- ~=======================
D.. te :=======~J I ­
Plac e [ J~[~S~ig~n_:_____________________________________

(n)Coda Offices Corporate' Offi ce Gandhin Jar : 079 - 8 6 7 43 2 8 9/3 11 • dsc sales@n code .in

o Ih i Bang310re M umba i
011-264522 79/ 80 080 -2520662 2 022 -2_ 04 8 90a
Iwrthsa les @n code .in southsales('!lncode. in I lI mbaisale @ncode i n

V 5.1
Toll Free: 1800-419-4455
www.ncodesolutions.com ( )
Corporate Onlce : 14th Floor. Tower One, Road 5C, Zone 5, GuJarat Intemattonol F'lnftnce Tech Cily (GI FT City}, Gandhrr agar - 38 2 3M;.
p (j ~e ,: 2 · 4
 Passport
Seva
Service Excellence

Subscriber Details

Request Type o Fresh o Renewal o Replace

Surname Given Name' Initials
Name' L - -_ _ _ I I"-----_ _ _ _ _1'----_
1 _ _- '

Designation' 1L -_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~
Role' IL _ _ _ _ _ _ _ _ ~

SPHQIDPHQ (Police users')

Superannuation Date (MEA users') 1

L -_ __ _______ ~

Organization Name' 1
L -_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ __ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~

Subscriber Declaration

I hereby declare that all the information provided on the application form for the purpose of obtaining a digital certificate is true and correct to the best of

my knowledge.

Subscriber Signature'

Date'

Place'

© 2002-2013 Tata Consultancy Services Limited. Version 1.0