» e-Secure , e-Sure e-Safe ie Class 2 code Registration Form for Class 2 Digital Certificate Customer lentfiction Number: (fr office use ony) vaiaty | avew [J 2yew (7)] {type | ony sing (—). ston ent v oO v0 y San0 |). Slane nen savevoan waa Avelicant Name seman L eg! Email io Date of itn oe the photagrash extended I ieee | ee spptcation form Residential Address (As mentioned in attached supporting) Town/City/District State/Union Territory PIN Contact No. PH Mo Identity Detail of Applicant _[ Please tick any one and enclore the copy of same *PAN [/] Postottice [-] Driving [-] Passport [7 Govt, [-] Copy of Bank Account Passbook contiaining photo & signed cars — 1D Cars License ID Card. — by applicant with attestation by concerned Bank Officer ‘*For PAN based DSC, pls provide the PAN Card detalls and enciose the copy of same. I nereby agree that! have read and understood (n)Code Solutions CA CPS and the subscriber agreement and promise to abide the same. | have reac ‘and understood guidelines for storage of private Kays mentioned in(n)Cada Solutions CPS and risk involved by using other storage devices to store private kays. | shal be held responsible forall sks arising out of not using USB Crypto Tokens to store private key. DETAILS REQUIRED IF APPLICANT IS FOREIGN NATIONAL: Nationallty Visa Details Passort No, INSTRUCTIONS: 1. Please filth form in English only in lope format 6. supporting documents shouldbe atested by Gazetted oficer Bank 2. Tho details ar requrod to obtain Cass 2 Individual Certificate and wil “Manger or Past Mastor. Altoratively the appicant can prosent bear Object Ienteation as 2.16.366.100.2.2 tginals to LRA for verifeation and atestaton 3. Incase Keypair has been compromisedosdeleted, please apaly for 7. The Vality of addross prof incase of uty ils shall nt bo older revocation of cartes than 3 months fom the date of aplication 4. Incomplete appication is liable for Rejection, 8. For any assistance Please get in touch with us at 5, Please refer to the CPS for more information. <éscsuppori@ncodein or cal: 1800 - 233 - 1010. Date Place Signature of Applicant Verified by (n)Code Office For LRA use only All Documents CI ed & Verified by {All Documents & Verified by Seal & Signature LRA Name, Seal & Signature vs CO? |) Page 1) 1-2 5 Toll Free : 1800 - 233 - 1010 = www.ncodesolutions.com n» e-Secure , e-Sure e-Safe Class 2 (n)Code Individual Cortes Solutions De emer elt: teeta ita Customer Identification Number : (for office use only) { Documents Required for Verification Checklist of the document to be submitted with Application 1 Attested copy of any one documents as proof Identity. (Please tick the one submitted) CR @ Driving (Gp Passport Post Office (> Government Card ___ License 10 card 1D Card em Copy of Bank Accuont Passbook Document as pro! 2) Attested copy of documents as proof of Address. (Please tic (J Risphone Electricity Bill with attested photograph by the bank of of Address (Please tick the one submitted) fone submitted) |_| ipcarg (OR) | Gonnecton °% ea) [| vote / Passport pis [| Property Tex Gorpoaton Tex [| water Driving ___ Municipal Corporation Receipt | il | Licensee ca) [| Bank sttement @ | |_| attested by the Bank Services Tax / VAT Tax / |__ Sales Tax Reg. Certiticatte Payment Details (Applicable for applicant obtaining DSC from any of (n)Code Offices) ‘Cheque / D.D. to be Drawn in favour of “(n)Code Solutions, Division of GNFC Ltd” (Chaque should ba "Paya! Dat Ps ) Bank Name DD / Cheque No, Amount leer kaa Corporate Office Ahmedabad : 079-4000 7300 + dscsales@ncode.in Mumbai 022-22048908, mumbaisales@ncode.in v4 Page 1) 2-2 Dethi Bangalore Chandigarh ‘Surat 011-26452279/80, (080-25272525 0172.2707732 0261-3003690, northsales@ncode.in _southsales@ncode.in | punjabsales@ncode.in__suratsales@ncode.in Toll Free : 1800 - 233 - 1010 www.ncodesolutions.com n Solutions, 301, GNFC Infotower, Bodakdev, Anmedabad-360064