Request for New PAN Card Or / And Changes Or Correction in PAN Data

Only 'Individuals to affix recent photograph (3.5 cm x 2.5 cm)

Permanent Account Number (PAN)

1 Name
Please Tick as applicable Last Name / Surname Shri

Signature/ Left

Smt. Kumari M/s

Middle Name

Thumb/ Impression First Name

Name you would like printed on the card

2 Father's Name (Only 'Individual' applicants: Even married women should give father's name only) Last Name / Surname First Name
Middle Name

3 4 5 6 7

Date of Birth / Incorporation / Agreement / Partnership or Trust Deed / Formation of Body of Individuals / Associations of Persons Sex (For Individual Applicant only) Please Tick as applicable Photo Mismatch Signature Mismatch Address for Communication Please Tick as applicable Office Name (to be filled only in case of office address) Flat/Door/Block No. Name of Premises / Building / Village Road / Street / Lane / Post Office Area / Locality / Taluka / Sub - Division Town / City / District R Male

D D M M

Y Y Y Y

Female

or

State/Union Territory

Pin
(Indicating PIN is mandatory)

8 9

If you desire to update your other address also, give required details in additional sheet.
STD Code Tel. No.

Tel. No. email ID

10 Mention other Permanent Account Number (PANs) inadvertently allotted to you

PAN 1 PAN 2
I true to the best of my information and belief. I have enclosed

PAN 3 PAN 4
, the applicant, do hereby declare that what is stated above is (number of documents) in support of proposed changes/corrections.

Verified today, the D D M M Y Y Y Y Signature/ Left Thumb Impression of Applicant (inside the box)