COMMON APPLICATION FORM FOR DSC (PAPERLESS)

CLASS: CLASS 3

USER TYPE : IND VALIDITY : 2 YEAR CERTIFICATE TYPE : SIGNATURE APPLICATION ID : 661848

APPLICANT DETAILS: EKYC TYPE : AADHAAR_KYC

SIGNER ID : GLAPS0457Q@PAN.SIGNX
VERSION:- 1.0
NAME SANJAY KUMAR SHAH PAN GLAPS0457Q GENDER MALE DOB 10-05-1991

MOBILE +91-9691981411 EMAIL ER.SANJAYKUMARSAHU@GMAIL.COM PINCODE 486886

ADDRESS TUSA KHAND POST TIYARA TUSA KHAND SINGRAULI SINGRAULI

CITY SINGRAULI STATE MADHYA PRADESH COUNTRY INDIA

AADHAAR NO (MANDATORY FOR AADHAAR EKYC) 4215

PSEUDONYM (ONLY IN INDIVIDUAL CASE) BIK1NVP8OLZ4SW9J03HX6AQGED7F2TRC

AUTHORIZED SIGNATORY DETAILS: EKYC TYPE : PAN_KYC SIGNER ID : NA

NAME NA PAN NA GENDER NA DOB NA

EMAIL NA MOBILE NA PINCODE NA STATE NA

ADDRESS NA CITY NA

COUNTRY NA AADHAAR NO (MANDATORY FOR AADHAAR EKYC) NA

ORGANIZATION DETAILS: ORGANIZATION TYPE NA

ORG PAN NA ORG NAME NA GST NO NA

DEPARTMENT NAME/IEC CODE NA BRANCH CODE (FOR DGFT) NA PINCODE NA

ORG ADDRESS NA CITY NA

(ADDITIONAL INFORMATION REQUIRED ONLY FOR DOCUMENT SIGNER CERTIFICATE)

HOUSE IDENTIFIER NA LOCALITY NA

STREET NAME NA TOWN NA

APPLICANT’S DECLARATION: I HAVE READ, UNDERSTOOD & AGREE TO THE TERMS & APPLICANT’S SIGNATURE
CONDITIONS MENTIONED IN THE SIGNX CPS & THE SUBSCRIBER AGREEMENT. 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.

AUTHORISER’S DECLARATION: I HAVE READ, UNDERSTOOD & AGREE TO THE TERMS & AUTHORISER’S SIGNATURE
CONDITIONS MENTIONED IN THE SIGNX CPS & THE SUBSCRIBER AGREEMENT. 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.

RA DECLARATION: - DETAILS ENTERED ON SIGNX PORTAL IS AS PER THE INFORMATION DOCUMENTS SUBMITTED BY THE SUBSCRIBER.

RA NAME SAROJ KUMAR SHAH RA ID RA SIGNATURE