DIGITAL SIGNATURE CERTIFICATE REQUEST FORM
(
On-Line
)
Type of Application/Subscriber
*
Dealers of Commericial Tax
Vendor of CEO office
Government Employees
High Court/District Court/Judicaries
National Informatics Centre(NIC)
PSU & Statutory Bodies
Registered Companies
1.
Class of Certificate Required
*
Class I
Class II
Class III
2.
Certificate Required (Purpose)
3.
Certificate validity (Max. 2 Year)
*
Two Year
One Year
4
Name
* (In Block Letters)
First Name
Middle Name
Surname
5.
Designation (Optional)
6.
E-mail Address (Official E-mail ID preferred)
7.
a)Office Address
*
Ministry/Department (Optional)
Telephone (
with STD Code
)
Official
(eg. 0771-2420120)
Residential
b)Residential Address
8.
Identification Details (One or More)
*
Employee Id/Code No
.
Passport No.
PAN Card No.
Voter's ID Card No.
Driving License No.
PF No.
Bank Account Details
Ration Card No.
9
In case the application is for a device then details of Server/ Device for which the certificate is being applied for must be filled. (Deatils forServer Certificate)
Web Server
Services
IP Address
URL/Domain Name
Physical Location
10
The following details will be used in Certificate subject
Organization
*
Organization Unit
*
Locality/City
*
State
*
Country
*
India
11
DD Details
?
Bank Details
*
DD Amount(Rs.)
*
DD Number
*
DD Date *
(dd/mm/yyyy)
12
District Name
Bastar
Bijapur
Bilaspur
Dantewada
Dhamtari
Durg
Janjgir Champa
Jashpur
Kabirdham
Kanker
Korba
Korea
Mahasamund
Narayanpur
Raigarh
Raipur
Rajnandgaon
Surguja
Point Numbers 13 & 14 are applicable only for Dealers who are applying through Commercial Tax Department of Chhattisgarh
13
Circle Name
Jagdalpur
14
TIN Number
Write your Security Code here as showing in the image...
Your Security Code is