Digital Signature Certificate

Digital Signature Certificate (DSC) Application:

For Individuals

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Instructions for filling in the application form:

Please ensure that you are filling the form below for a DSC that is intended for your use only.
Ensure that the form is complete in all respects. In case you require Assistance, please consult your Authorized SafeScrypt Representative.
Incomplete forms would delay the certificate issuance process. Therefore please fill in all fields unless specified as "optional".
Use block letters only to fill in the form.
You are urged to review our CPS while applying for a certificate.
Detailed instructions for certificate installation will be provided by your Authorized SafeScrypt representative.
All the mandatory Fields are marked with a "*"
You can fill up most of the details on the form directly on your computer and print the same. This will ensure legibility of the data. If you have to fill details with a pen please do so using BLOCK LETTERS.

For Official use only
Partner Code
City
Date of Application
CD serial No.
Remarks
DSC Issued on

Section 1:
Class of Certificate : RCAI Class 2		Certificate Type : Individual
Certificate Validity * (Tick as applicable)		1 Year 2 Years
Token (Tick if Yes)		Token
First Name*			Self Attested Photograph
Middle Name
Last Name*
Date of Birth*
Sex*	Male Female

Contact Address Details (as per Applicant"s Bank records or proof of adress submitted )
Flat/ Door/ Block No. *
Name or Premises/ Building/ Village *
Road/ Street/ Lane/ Post Office *
Area/Locality/Taluka/Sub-division*
Town/ City/ District *
State/Union Territory*
PIN Code *
Telephone Number *
Mobile Number

Section 2:

Please submit a VALID e-mail address which will be used by the applicant to receive his Digital Certificate. The same e-mail address should also be used while enrolling for the Digital Certificate online. *

Section 3a: Identity Proof Details
* Please provide details of a Government-issued Photo Identity Proof being enclosed by you. * Acceptable Photo IDs include Passport, Voter ID Card, PAN Card, and Driving License. * If you are presenting any other type of Government-issued Photo ID, please specify details of the same in the ‘Identity Proof submitted’ field below. * The photocopy of the specified Photo-ID is required to be duly attested by your Banker /Public Notary /Gazetted Officer/ SafeScrypt Prevalidated Signatory. * For ICSI and ICWAI members, a Photo ID is not required. Select/ Enter "ICSI Membership" or "ICWAI Membership" against Identity Proof submitted and enter your Membership Number against "Identity/ Membership Number".
Identity Proof submitted *
Identity/Membership Number *

Note for ICAI / ICWAI Members: If your address and contact details in your Institute’s membership database are not updated and current, then you will be required to follow the process specified for non-members

Section 3b: Address Proof Details (Not applicable for ICSI/ICWAI members)

Please specify the Address Proof Document that you will be submitting along with this application. This document is only required if your document is being attested by a SafeScrypt Prevalidated Signatory instead of a Bank Manager in Section 4.

Proof of Address Document submitted *

The Address Proof Document needs to be attested by the SafeScrypt Prevalidated Signatory

Declaration:

I hereby declare that all information provided on this Certificate Application Form for the purpose of obtaining a digital certificate is true and correct to the best of my knowledge.

Signature of the Applicant *

Date * (DD-MM-YYYY)

Place *

Section 4: Attestation by Banker or SafeScrypt Prevalidated Signatory (Not applicable for ICSI/ICWAI members)

I, as a Bank Manager, hereby certify that theapplicant, as appearing above, maintains an address is hereby attested as being correct with reference to the records maintained by the Bank.
OR
I, as a SafeScrypt Prevalidated Signatory, hereby declare that the applicant is known to me and has presented his original documents of Proof of Address photocopies of these documents as TRUE COPIES.

Signature & Seal of Bank Manager / Signature of SafeScrypt Prevalidated Signatory *

Date * (DD-MM-YYYY)

Name * (Name of the Banker or Name of the SafeScrypt Prevalidated Signatory)

Name of the Bank & Branch *
(Applicable if attestation is by a Bank Manager)

Note: SafeScrypt, at its discretion, will make a telephone call to verify the details of this attestation.

Section 3b: Address Proof Details (Not applicable for ICSI/ICWAI members)
Please specify the Address Proof Document that you will be submitting along with this application. This document is only required if your document is being attested by a SafeScrypt Prevalidated Signatory instead of a Bank Manager in Section 4.
Proof of Address Document submitted *

Declaration:
I hereby declare that all information provided on this Certificate Application Form for the purpose of obtaining a digital certificate is true and correct to the best of my knowledge.
Signature of the Applicant *
Date * (DD-MM-YYYY)
Place *

Signature & Seal of Bank Manager / Signature of SafeScrypt Prevalidated Signatory *
Date * (DD-MM-YYYY)
Name * (Name of the Banker or Name of the SafeScrypt Prevalidated Signatory)
Name of the Bank & Branch * (Applicable if attestation is by a Bank Manager)
Note: SafeScrypt, at its discretion, will make a telephone call to verify the details of this attestation.