sifysafescrypt" Digital Signature Certificate Subscription Form ere Designation * Solf Attosted Photo Date of Birth” Gender *: Male Female ‘Address (Residential address in case of aha or Oganzation ediress n cate of DSC wth ORG ) Organisation Name * (Mandatory in case of ORG OSC) = a oor NoJBuilding Name * Road Steet Post Oc * vest own’ ity District * Gecuseuas eat State/ Union Territory * forests creat a Country PIN Code" (a Telephone Number* (with STD Code): Mobile Numbert Email id* Section 2: Identity Proof Details [Photo Identity Proof * ‘Address Proof* Identity Proof Name ‘Address Proof Name} (€5:Pon Cart OL, Passer.) (€p:Peege OL Let Identity Proof Number "eae i) (oe* Subscriber's signature should appear on the Photo ID Prook Se | hereby declare tha ll the information provided inthis Subseription form for the purpose of obtaining a dgial certificate is true and correc to the best ‘of my knowledge. | am aware, asa subscriber for the cigtal signature certificate, the duties and responsible which are applicable under the SafeScrypt ‘CA.CPS (nitpsfiwww safescrypt convpaticps pd) and also under the Section 71 of IT Act which stipulates that if anyone makes a misrepresentation or ‘suppresses any material fat from the CCA or CA for obtaining any DSC such person shall be punishable with impr'sonment up to 2 years or with fine up to.one lakh rupees or with both Sion ofthe Subecrba* | Date: [To] ] Place" ] Noto" Subsorba haat sign befor the Authorised LRAParner or Class3 DSC. Se I ‘acknowledge by my signature, that the Subscriber information inthis document is complete and accurate as per our office records. | fully understand that the Subscriber is responsible to transact on the Organisation's behalf and | wil ‘ensure timely revocation of Digital Signature Certificate in case the employee leaves the company in future, Signature & Organisation seal nes ‘Attestation By Sify Authorised LRA/Pariner® (For Class 30SC Only) | hereby dectare that the subscriber has personally appeared before me and submited the Partner Name: ‘cxignal document copies. Cc Sify RA: owe (To) Es] ene FF | pot rine Note": Safescryptat its ciscretion, will make a telephone call to very the detals ofthe Subscriber.