sitysafescrypt | Digital Signature Certificate Subscription Form Peete ry Name: [ | |_| ml “Tl [ TT I [ Desisnation: [| OI * Sol Atesed Photo pateotainn’: [Po ][Pe| boy Le] — Gender: [-]male [| Female Adress ena ates ctf Oat aes meas of 1 wah ORS) ‘eriaaion Nam [ | Pleo ORO O86) Door NeBuling Name* [ I I - , Road/ Street/ Post Office * L I “tne eoue Town/ City/ District * I opera pe Nene, Desens Stato! Union Territory * LLL I =I = areas Telephone Number* (with STD Code): [ | Country" [] PIncoser \ [ | Mobile Number Photo Identity Proof [__ Address Proof ldentiy Proof Name ‘Address Proof Name’ (€aPon Card, Pept.) (SgePasor Late Identity Proof Number ‘Tana (oi Subscribar's signature should appear on the Phoio 1D Prool hereby declare that all the information provided inthis Subscription form for the purpose of obtaining a digital cotiieate is rue and correct to the best ‘of my knowledge. | am aware, asa subscriber forthe digital signature certificate, the cuties and responsibilties which are applicable under the SafeScrypt CA.CPS (nitpssimmu.satescrypt comvpaticps pdt) and also under the Section 71 of IT Act which stipulates that if anyone makes a misrepresentation or ‘suppresses any material fat from the CCA or CA for oblaning any DSC such person shall be punishable with imprisonment up to 2 years or wih fine up tone lakh rupoes or with both date’: [To] Te] DDD) Plana [ ] Note": Subscriber has o sign bore the Authorised LRA/Partner for Class DSC. ‘Section 4: Authorisation (only for ORG DSC) acknowledge by my signature, that the Subsenbar information in this document is cape ‘and accurato as per our fice record. |fuly understand thatthe Subscriber is responsible to transact on the Organisation's behalf and | wil ‘ensure timely revocation of Digital Signature Cerificate in case the employee leaves the company in future Signature & Organisation seat"| Attestation By Sify Authorised LRA/Partner* (For Class3DSC Only) | hereby declare thatthe subscriber has personally appeared before me andssubmited the Partner Name: ‘original document copies. Sily RA: Signature and Seal *[ ove] SITS ee: | atin Salescrypt tits discretion, wll make a telephone call to vey the ubseriber