<p> Sify | Safescrypt LRAA Application form</p><p>Submitted by</p><p>SifY Technologies Limited</p><p>Version 1.0, 13th SEP, 2016</p><p>Document Information</p><p>Document Details</p><p>Sify | LRAA Application form Type of document: Confidential © Sify Technologies Ltd 2012 1 | P a g e Document Title Sify | LRAA Application form</p><p>Document SIFY/Safescrypt/LRAA/May 2014 Reference</p><p>Date 13/09/2016</p><p>Statement of Confidentiality</p><p>This document contains confidential information to be used solely for evaluating Sify Technologies Limited (“Sify”). The information contained herein is to be considered confidential. The recipient by accepting this document agrees that neither this document nor the information disclosed herein, nor any part thereof, shall be reproduced or transferred to other documents, or used or disclosed to others for any purpose except as specifically authorized in writing by Sify.</p><p>SIFY LRAA SIGN UP– FACT SHEET Nature of Business Retail Enterprise SME/SOHO/ OTHERS</p><p>Sify | LRAA Application form Type of document: Confidential © Sify Technologies Ltd 2012 2 | P a g e Name of Organization : Address – Address-2 : (If any)</p><p>Phone : Fax : E-Mail : </p><p>Tick whichever applicable Pvt Ltd : Public Ltd : Partnership: Other’s :</p><p>Name of Key Designation e-mail id Contact Person’s (Owner/ Phone/Mobile Director)</p><p>Mandatory Fields Company registration Number : NO VAT / Sales Tax / Service Tax number :NO Year of Incorporation : NO</p><p>Office Computer space Manpower Systems (Sq.Ft) ( Qty ) (Units) Head Office INDORE Branch Office-1 (If applicable) Branch Office-2 (If applicable)</p><p>Whether familiar/associated with DSC business – Yes / No</p><p>If yes, with which CA (Certifying Authority) - </p><p>(Few words describing about your company strengths / achievements / business goals )</p><p>Sify | LRAA Application form Type of document: Confidential © Sify Technologies Ltd 2012 3 | P a g e Name of the LRAA operator (Need to obtain class 3 certificate from Sify)</p><p>Sify LRA Recommendation ( Recommendation for appointment with justification )</p><p>I am going to client office and checked all fields arwe ok..so pls approve this</p><p>Authorized Signatory of LRA (Director/Owner) Signature & company seal Sify Channel Manager Recommendation ( Recommendation for appointment with justification )</p><p>Date of Visit & location :</p><p>I have understood all the terms and conditions of process and compliance of Sify Technologies Ltd (Safescrypt CA) and will abide to them.</p><p>Name:NEVASE AMIT Signature & Company seal: </p><p>(LRAA’s Authorized Signatory) Date: </p><p>Passport size photo Note : Kindly attach company profile with this sheet. (Indv- PAN card and Address Proof )</p><p>Sify | LRAA Application form Type of document: Confidential © Sify Technologies Ltd 2012 4 | P a g e</p>