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For office use only Digital Signature Certificate Subscription Form I , _______________________________________________________ acknowledge by my signature, that the Subscriber information in this document is complete and accurate as per our office records. I fully understand that the Subscriber is responsible to transact on the Organisation’s behalf and I will ensure timely revocation of Digital Signature Certificate in case the employee leaves the company in future. Signature & Organisation seal* SafeScrypt CA Services brought to you by: Photo Identity Proof* Address Proof* Identity Proof Name Address Proof Name Identity Proof Number ( Eg: Pan Card, DL, Passport, ...) Note*: Subscriber's signature should appear on the Photo ID Proof. ( Eg: Passport, DL, Latest Telephone Bill, ...) I hereby declare that all the information provided on this Subscription Form for the purpose of obtaining a digital certificate is true and correct to the best of my knowledge. I am aware, as a subscriber for a digital signature certificate, the duties and responsibilities are applicable under the IT Act, India and the SafeScrypt CA’s CPS https://www.safescrypt.com/pdf/cps.pdf . Signature of the Subscriber* Date*: Place*: Note*: Subscriber has to sign before the Authorised LRA/Partner for Class3 DSC. * Self Attested Photo Name*: Addr ess (Residential address in case of Individual or Organization address in case of DSC with ORG ) Organisation Name * : (Mandatory in case of ORG DSC) Door No/Building Name * : Road/ Street/ Post Office * : Town/ City/ District * : State/ Union Territory * : Country* : PIN Code* Telephone Number* (with STD Code): : Mobile Number* : Date of Birth*: Gender *: Male Female Designation : Section 4: Authorisation (*only for ORG DSC) Section 3: Declaration Section 2: Identity Proof Details Section 1: Subscriber Details Partner Name: City: Date of Issuance: I hereby declare that the subscriber has personally appeared before me and submitted the original document copies of ID proof. I have verified the same with TRUE COPY. Date * Name * Signature and Seal * Note*: Safescrypt at its discretion, will make a telephone call to verify the details of the Subscriber. Attestation By Sify Authorised LRA/Partner(*For Class3 DSC Only) Individual With Org Name Class of Certificate Type of Certificate Certificate Validity Signing Encryption Class 2 Class 3 1 Year 2 Years Sify Technologies Limited, 2nd Floor, Tidel Park, #4 Rajiv Gandhi Salai, Taramani, Chennai - 600113. E-Mail: email@example.com Email id* :