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APPLICATION FOR DIGITAL SIGNATURE CERTIFICATE

(FOR Individual)

Application ID Number (For office use only):

82550

Any discrepancy or inconsistency in the form will lead to delay and / or rejection Attestation of documents by: Public Notary OR Gazetted Officer OR Bank Manager OR Chartered Accountant (CA) or Company Secretary (CS) OR present originals to our Registration Authority for verification & attestation. Ensure that person attesting shall affix his / her signature, full name, address and membership number (CA or CS) on all the attested documents without which attestation is not acceptable. All subscribers are advised to read Certification Practice Statement of e-Mudhra available at www.e-Mudhra.com Applicants for Class III shall present themselves at the RA location where the registration form for Digital Signature Certificate was sent, for verification of physical presence. Legal proceedings will be initiated against cheque bounce.

Affix recent passport size photograph of the applicant.

Applicant to sign across the photograph extended to application form

1A. CERTIFICATE CLASS: Class 2 Gold Individual

1B. CERTIFICATE TYPE: Signature

2. CERTIFICATE VALIDITY: 1 Year(s)

3. USB TOKEN: Not Required

APPLICANT DETAILS(As per applicant's valid ID Proof at Sl.No.14 below) 4. Name: Salutation Mr. 5. Date of Birth: 7. Father / Spouse Name: First Name CHANDRASHEKHAR 8. Nationality: Indian 9. Residential Status: CONTACT DETAILS 10. Office Address: Organisation Name Designation Department Flat/Door/Block No. Name of the Premises/Building/Village Road/Street/Lane/Post Office Area/Locality/Taluka/Sub-division Town/City/District State/Union Territory Pincode Telephone No. Fax No. Personal Personal Personal NA NA NA NA NA NA NA NA NA Middle Name Last Name/Surname PANDEY Resident First Name RATISH 01-Mar-1981 Middle Name CHANDRASHEKHAR 6. Gender: Last Name/Surname PANDEY Male

11. Residential Address: (Please attach attested copy of valid address proof of any one: Passport/Driving License/Electricity Bill/Telephone Bill/PF Statement) Flat/Door/Block No. Name of the Premises/Building/Village Road/Street/Lane/Post Office Area/Locality/Taluka/Sub-division Town/City/District State/Union Territory Pincode Telephone No. Mobile No. A-603 Runwal Heights LBS Marg Mulund West Mumbai Maharashtra 400080 02225901761 9833673556 IDENTIFICATION DETAILS 12. Address for Communication: 13. E-Mail ID: 14. a) PAN Number: 14. b) Valid Identity Details: Residence ratish.meet@gmail.com AKHPP8947J AKHPP8947J PAYMENT DETAILS 15. Mode of Payment Cheque/DD Payment Details Cheque/DD No. Amount Rs. Date

DECLARATION I hereby agree that I have read and understood the provisions of e-Mudhra Certification Practice Statement (CPS) and the subscriber agreement and will abide by the same. The information provided in this Digital Signature Certificate request form is true and correct to the best of my knowledge and I accept publishing my certificate information in e-Mudhra repository. Place: Date: Signature of the Applicant:

Name of the Applicant: RATISH CHANDRASHEKHAR PANDEY Seal and Stamp(If available):

CHECK LIST OF DOCUMENTS TO BE SUBMITTED ALONG WITH THE APPLICATION 1. PAN Card 2. Life Insurance Premium receipt 3. Latest coloured photograph of the applicant to be pasted on the application form TO BE FILLED BY RA OFFICE ONLY I declare that the applicant has provided correct information in this application form. I have checked and verified the application form and supporting documents. RA Name: Signature: Place: Date:

RA Seal & Stamp CONTACT DETAILS e-Mudhra 3i Infotech Consumer Services Limited, 4th Floor, Prince Technopark,# 10, Rajiv Gandhi Salai,Thoraipakkam, Chennai 600 096,Tamilnadu, India Phone: +91 44 3065 3500 | Fax: +91 44 3065 3100 Email: info@e-Mudhra.com | Website: www.e-Mudhra.com

To, TAXSMILE.COM INDIA PVT. LTD. 3I INFOTECH CONSUMER SERVICES LTD., 3RD FLOOR, "SAI ARCADE", NO. 56, OUTER RING ROAD,, DEVARABEESANAHALLI, NEXT TO ADVAITH HYUNDAI SHOW ROOM, BANGALORE, BANGALORE - 560036, KARNATAKA, INDIA

From, RATISH PANDEY A-603, RUNWAL HEIGHTS, LBS MARG, MULUND WEST, MUMBAI-400080 , MAHARASHTRA, INDIA