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Application Form PDF

This document is an application form for an encryption or signature certificate from a government organization. It requests applicant information like name, date of birth, organization details, identification documentation, and declarations agreeing to terms. Authorized signatories from the applicant's organization must also fill out sections to authorize the application and verify applicant information. A registration authority official then reviews and verifies the application before finalizing the certificate request.

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KRPHS
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339 views1 page

Application Form PDF

This document is an application form for an encryption or signature certificate from a government organization. It requests applicant information like name, date of birth, organization details, identification documentation, and declarations agreeing to terms. Authorized signatories from the applicant's organization must also fill out sections to authorize the application and verify applicant information. A registration authority official then reviews and verifies the application before finalizing the certificate request.

Uploaded by

KRPHS
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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APPLICATION FORM - SIGNATURE / ENCRYPTION CERTIFICATE

FOR GOVERNMENT ORGANIZATION

Application ID: (S) s h s j k h d k s j (E) h s h d u s d o d h (For Office Use Only)

PLEASE FILL IN BLOCK LETTERS ONLY. ALL FIELDS ARE MANDATORY


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

APPLICANT INFORMATION
Affix recent passport
Applicant
Name houhdofhohe eoifdhueow foiefew size photograph of
the applicant duly
Date of Birth D DMMY Y YY Gender Male Female Nationality I ND I A N signed across

Organisation
Name

Department

Org Address

CLASS:
Class 1 Class 2 Class 3

City Pin code


TYPE:
State Signature Encryption Combo
PAN of Applicant Mobile
VALIDITY:
Aadhaar (NOTE : Either PAN and / or Aadhaar No. is mandatory)
1 Year 2 Years
Email ID

DOCUMENT PROOF (attested by Authorized Signatory of the Organization)


Document required:
Copy of Applicants Goverment ID Card / Letter from Organization / Pay Slip

Authorized Signatory Organisational ID Card / Self-Attested Letter of Organizational Identity


Copy of PAN Card of Applicant, if PAN provided

Copy of Aadhaar Card of Applicant, if Aadhaar provided

DECLARATION BY APPLICANT AUTHORIZATION


I hereby agree that I have read and understood the provisions of e-Mudhra Certification Practice Statement (CPS) I hereby authorize this application on behalf of the
and the subscriber agreement and will abide by the same. The information provided in this form is true & correct to organization.I hereby confirm the mobile number of
the best of my knowledge. I accept publishing my certificate information in e-Mudhra repository. I am aware of risks
Applicant given above. In case of class 3, I confirm
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. the Physical Verification of Applicant.

Date
Signature of the applicant
Place (As in ID proof | Blue Ink Only) Authorized Signatory (Sign and Seal)

TO BE FILLED BY RA OFFICE 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 hereby
take full responsibility for any wrong verification made, or wrong documents submitted for the application.

Date
RA Name, Code & Seal Signature of RA

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 : [email protected] Website: www.e-Mudhra.com.

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