Digital Signature Certificate Reissue Form
(For Smart Card Users)
To, Date: ___________
DP Name : ________________
DP Id : ________________
Dear Sir/Madam,
I/We request you to revoke my /our certificate and reissue new certificate for the following reason:
Reason (Tick 4 in the appropriate box below)
? Forgot PIN
Lost Smart Card
Damaged Smart Card
Other Reason (please specify)___________________________
Details for the reissue:
(Tick 4 in the appropriate box below)
? Option I : Use existing Smart Card (enclosed, if the smart card is unusable / damaged , the participant or NSDL will nor be responsible)
Option II : New Smart Card required,
Tick 4 any one of the following
Full Smart Card Kit required.
Only Smart Card required.
Name of smart card owner : ______________________________________
Certificate Serial No. : ______________________________________
Smart Card Serial No. : ______________________________________
User Id (any One) : ______________________________________
Corresponding Client Id : ______________________________________
(Authorised Signatory)
(to be signed by either sole holder OR the Power of Attorney holder operating the account appointed by sole holder/ joint holders)
For office use only (to be filled up by DP. not to be filled up by client)
The application is verified with the details of the beneficial owner’s account and certify that the same is in order.
Name of the Authorised Signatory : __________________________
Signature : __________________________
(DP’s stamp and Date)
For office use (to be filled by NSDL)
Maker : _____________ Sign & Date : __________
Checker : _____________ Sign & Date : __________
Acknowledgment
Date: ______________
Received an application for Re-issue of Certificate for operating SPEED-e service from __________________________ having Client Id _____________.
(DP’s Stamp & Signature)