Government of India

Ministry of Electronics & Information Technology

NATIONAL INFORMATICS CENTRE
VPN Subscription Form
(In case of manual submission, the completed application form, duly sealed and signed, must be uploaded
back to eForms portal by the applicant and his/her Reporting/Nodal/Forwarding Officer)
Please sign on each page. Entries marked asterisk(*) are mandatory

Registration number :VPN-FORM202404050172

1) Ministry/Department* : Finance / Department Of Revenue (CBIC)

2) Applicant Name* : RajMeena
3) Applicant Email* : rajk.m142301@gov.in
4) Applicant Mobile* : +919521431483
5) Applicant Designation* : Stenographer Grade I
6) Applicant Employee Code : G14RKMM2301
7) Applicant Postal Address* : TRIMURTI COMPLEX, SECTOR 16A, NERUL WEST, NAVI MUMBAI,
MAHARASHTRA
8) Applicant State Of Posting* : MAHARASHTRA
9) Applicant District* : Thane
10) Applicant Pincode* : 400703
11) Reporting/Nodal/Forwarding Officer Name* : NAVEEN KUMAR
12) Reporting/Nodal/Forwarding Officer Email* : naveen.kumarde@gov.in
13) Reporting/Nodal/Forwarding Officer Mobile* : +917032744441 Designation* : Assistant
Commissioner
14) Co-ordinator Email* : motir.d108901@gov.in

NOTE: Details of applied ips* :

Server IP Server Destination Application Action Type

Location Port URL
10.194.164.126 443 https://eoffice.c Add
bic.gov.in

Signature of the Applicant with date and seal Signature of Reporting/Nodal/Forwarding Officer with date and seal

Signature of NIC COORDINATOR with date and seal

 Terms And Conditions

1. Fill one form for one IP only.

2. If administrator is from outside NIC, please get the form approved by NIC coordinator.
3. NIC does not capture any aadhaar related information.
 Application Approval Details for Reg No - VPN-FORM202404050172

Submitted By IP Details Datetime Submitted To Status

User 182.59.115.12 2024-04- naveen.kumarde Pending with

(rajk.m142301@gov.in, 4 05T15:45:54 @gov.in RO/Nodal/FO
+919521431483)

Reporting/Nodal/Forwar 152.58.2.119 2024-04- motir.d108901@ Pending with

ding Officer (NAVEEN 10T12:53:58 gov.in Coordinator
KUMAR,
naveen.kumarde@gov.in
, +917032744441)

Coordinator (Moti Ram, 157.10.249.5 2024-04- null Rejected by

motir.d108901@gov.in, 10T12:57:36 Coordinator
+919868108907)