Customer Identification Number: ____________________

(For Office Use Only)

Instructions: 1. Please fill the form in BLOCK LETTERS in English only 2. (n)21 Certificate refers to Class IIa 1. VALIDITY OF (n)21 2. PROFESSION 1 Yr. 2 Yr.

Affix recent passport size photograph of the Applicant

(sign across photo)

OTHERS

3. NAME OF THE APPLICANT(As required in the DIGITAL CERTIFICATE)

(Please ensure that the name as it appears in the Identity Proof matches with the name mentioned below)

4. RESIDENTIAL ADDRESS Town / City / District State / Union Territory Pin Telephone No.
(STD Code) Phone No Fax No

Mobile Phone No.

5. DATE OF BIRTH
eg. DATE DD MONTH MM YEAR YYYY

6. E-MAIL ADDRESS

7. IDENTITY DETAILS (Please tick and No. fill ANY ONE) Pan Card /Passport / Voters ID / Driving Lic. / PF Ac. --------------------------------------------------------------------------------------------------------------------------------------Contact Details:

Speed Esolutions Pvt Ltd 303-A, Prism Tower, Opp Lal khoti Subji Mandi Main Gate, Near JDA Flats, Lal khoti Jaipur-302015 Rajasthan Tel: 0141-4029027 (M) 9024568489 (E) dsc@speedesolutions.com (w) www.speedesolutions.com
page 1 of 2 Licensed Certifying Authority Version 1.1

Customer Identification Number: ____________________

(For Office Use Only)REQU IRED

Documents Required and Submitted by the Applicant A. Attested* Copy of any one: (Please tick the one submitted) Passport / Driving License / Voters ID / PAN Card / PF Statement/ PF Book / B. Attested* Copy as address proof of any one: (Please tick the one submitted) Latest telephone bill (landline or mobile) / Latest electricity bill / LIC receipt (if LIC policy is taken by applicant) Documentary Proof of Professional Membership (ICAI, ICSI, ICWAI) Latest Photograph of the applicant C. Only for Directors Declaration giving Director details duly attested by CA / CS as per the format given below
Note :* Attestation may be by a Bank Manager of a Nationalized or Private bank (excluding Cooperative banks) / Public Notary / Class I Gazetted Officer / Company Secretary/Chartered Accountant. *In case the address on application is same as on document submitted under A (as above) then document mentioned in B is not required --------------------------------------------------------------------------------------------------------------------------------------------------------------------------

I hereby agree that I have read and understood the provisions of the (n)Code Solutions CA CPS and the Subscriber Agreement and promise to abide by the same. Place : Date :

Signature Of Applicant

[Name:

Registration form for (n)21 along with verification documents can be sent to any one of the nearest LRA locations given on (n)Code Solutions CA website. Cheque / D.D. to be drawn in favour of SPEED ESOLUTIONS PVT LTD Cheque should be Payable at Par
Payment Details D.D. Cheque No. : ________________________ Date : ________________________ Amount: __________________ Bank Name : ____________________________________________ ________________________________________________________ LRA Name / Signature / Stamp LRA Details Checked & Verified By

Contact Details

Speed Esolutions Pvt Ltd 303-A, Prism Tower, Opp Lal khoti Subji Mandi Main Gate, Near JDA Flats, Lal khoti Jaipur-302015 Rajasthan Tel: 0141-4029027 (M) 9024568489 (E) dsc@speedesolutions.com (w) www.speedesolutions.com

Page 2 of 2

Licensed Certifying Authority

Version 1.1

Declaration by Applicant

I ____________________________________________________________( Applicant Name ) Hereby declare that the details mentioned in the application form are true & correct to my knowledge &belief. I hereby authorize Speed Esolutions Pvt Ltd and Sub Dealer to enroll & download my Digital Signature on my behalf.

____________________ Signature of Applicant

_____________________ Date & Place

Declaration by Proposer ( By CA/ CS/ ICWA/Any Other)

I______________________________________________________________________(Name) Certify that I have submitted the correct details for _____________________( Applicant Name) my client mentioned in the application form to get the DSC as required. ID proof & Address Proof are duly certified and attested by me.

___________________________________ Signature of Proposer With Stamp

________________________ Date & Place

Speed Esolutions Pvt Ltd 303-A, Prism Tower, Opp Lal khoti Subji Mandi Main Gate, Near JDA Flats, Lal khoti Jaipur-302015 Rajasthan Tel: 0141-4029027 (M) 9024568489 (E) dsc@speedesolutions.com (w) www.speedesolutions.com

DOCUMENTS REQUIRED & TO BE SUBMITTED BY THE APPLICANT FOR CLASS 2A

1. Application Form duly filled in. 2. Photograph of Applicant ( Must be pasted on form with Cross Signature ) 3. Duly Attested Photocopy of anyone of the following ID Proof of Applicant:

- Passport - Driving License - PAN Card Copy - Govt. Issued ID Card 4. Duly Attested Photocopy of anyone of the following Address Proof of Applicant: - Passport - Driving License - Latest Utility Bill ( Telephone Bill / Mobile Bill / Electricity Bill / LIC Receipt / Water Bill) Not older than three months - Ration Card - Voter ID Card - Bank Account Statement ( Not older than three months) 5. Declaration Letter (Format Attached ) Note: - All Supportive Documents must be attested by Public Notary OR Practicing CA/CS/ICWA OR
Gazetted Officer . - To obtain PAN Based Digital Signature , Photocopy of PAN Card is mandatory. - Payment Mode: Cheque/ DD Should be in favor of Speed Esolutions Pvt Ltd

Regards,
Speed Esolutions Pvt Ltd

Speed Esolutions Pvt Ltd 303-A, Prism Tower, Opp Lal khoti Subji Mandi Main Gate, Near JDA Flats, Lal khoti Jaipur-302015 Rajasthan Tel: 0141-4029027 (M) 9024568489 (E) dsc@speedesolutions.com (w) www.speedesolutions.com