To Be Filled and Signed By Authorized Signatory

1. Name of Organization * __________________________________

2. Account Type * Enterprise Sub-CA / Enterprise RA

3. Number of Certificates * __________________________________

4. Registration Number * __________________________________

5. Date of Incorporation/Agreement/Partnership * --/--/----

6. Particulars of Business: *

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 __________________________________

__________________________________

__________________________________

7. Income Tax PAN No.* __________________________________

8. Turnover in the last financial year Rs. _______________________

9. Names, Addresses etc. of Partners/Members/Directors

No. of Partners/Members/Directors * _____________________________

Details about Partners/Members/Directors

(For Information about more persons, please add separate sheet(s) in the format given below) *

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 _____________________________

10. Bank Details

Bank Name * _____________________________

Branch * _____________________________

Bank Account No. * _____________________________

Type of Bank Account * _____________________________

11. Type of Digital Signature Certificate required Class 3 Server Certificate

12. Purchase Order Number * _____________________________

__/__/____ (dd/mm/yyyy) ______________________
Date Authorized Signatory

(Signature with Official Stamp)

For Office Use

Customer ID: ____________________________________________

Instructions

1. Columns marked with * are mandatory.

2. For the columns marked with # details for at least one is mandatory.

3. Along with the completed and signed application form, please attach copies of three documents as mentioned below:

   1. Proof for organization name:

• For companies registered under the Companies Act - Copy of the Certificate of Incorporation (COI) and Memorandum of Association (MOA) attested by a Director of the organization.

• For partnership firms – Copy of the registered partnership deed attested by a partner of the firm.

• For sole proprietorship concerns – A banker’s attestation of the name of the sole proprietorship concern and the signature of the sole proprietor.

• For organizations created by an Act of the Parliament – A copy of the relevant Act or Government Gazette plus an attestation of the application form by an officer of the rank of Head of Department or above.

• For government departments – An attestation of the application form by a gazetted officer of the rank of Joint Secretary of above.

• For any other organization like a NGO, etc – Certificate issued by appropriate Government or Government Agency