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 ownerís account and certify that the same is in order.

Name of the Authorised Signatory : __________________________

Signature : __________________________

 

(DPís 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 _____________.

 

 

(DPís Stamp & Signature)