Digital Signature Application Form

FOR OFFLINE KYC

Application ID Class Class 2 Certificate Type Signature

1106850 Application Type Individual Validity 2 Year

Subscriber Details

Applicant Name: GURUCHARAN KRISHNAN

PAN: CATPG0374G Affix Passport Size Photo

With Cross Sign On It

Date Of Birth: 18-01-1999 Gender:

Aadhaar: N/A Mobile: 9003583525

Email ID: NA

Address: 48, NADU NEIKARA EDA STREET 1ST FL, PALAKKARAI, TRICHY, TIRUCHIRAPPALLI

City: TIRUCHIRAPPALLI State: Tamil Nadu Pincode: 620001

EKYC Code: 66017878446451a1aec826d6f21b5267

Declaration by Applicant

I confirm that the information provided by me in the digital signature application form is correct. I am aware that Section
71 of the IT act stipulates that if anyone makes a misrepresentation or suppresses any material fact from the CCA or CA
for obtaining any DSC, such person shall be punishable with imprisonment up to 2 years or with fine up to one lakh
rupees or with both.

I give my consent to VSign to use my KYC Account data for the purpose of this digital signature application & also
consent to receiving SMS and eMail communication from VSign regarding this application from time to time.
I also allow VSign to publish my certificate information in their repository.

I have read and understood and agree to the terms and condtions mentioned in the VSign CPS & the subscriber
agreement.

Applicant Signature Registration Authority Details

adnanjaweed96@gmail.com
Date: RA Code: DATAR HRISHIKESH ARVIND

Place: 9644410171

(This document is esigned by the applicant, in accordance to the Second Schedule of Information Technology Act.)
VERASYS TECHNOLOGIES PRIVATE LIMITED, 2nd Floor Bhavna Building, V.S. Marg Prabhadevi Mumbai- 400025
Website: www.vsign.in, Contact: 91 22 43156000, Email: info@vsign.in