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‘Request For New PAN Card Or/ And Changes Or Correction in PAN Data “ ry a Permanent Account Number (AN) (Ce 7 ABUT FAA gy 2 [o[ uy Please road Incucions for electng Bowes on lft margin of hie form, Seen ae 7 ‘(Liliane Fl expanded name to be mentioned as appearing nproot of entities or" ‘cuanto not pre) Phase select tte, [Z]asappcabie(]60i [Jee [human Evie | Last Name / Surname Awol /Al [cles Link ts [>| Tele|si/e) First Name. ® MolelP tit lajet Nil Nae Name you wo We eed one (DIARIO vial [chal | I [LJ 2 Detaits of Parents (applicable Fathers Name (Mandatory Even married Lact Name Sumame T at Frsthame | I isle Nar 1 Nother’ Name (optional Fst ame | t Select te name of ether ater oF mother which you may like fo be printed on PAN card elect one ony) Cece re opin rie hen PAN carl se wth athe a) Moners me Pasa ka appa) (1) bate ot Birtvincorporton/Ageemen’PartnersipTust Deed Formation of Body of invdualsor Association of Persons Day Month Year ola) (ei3| arelay) 4 Gender or ndividua applicant oni) [~]Male[]Female_[] Transgender (Please ck 28 appicable) Photo Mismaten {6 Signature Msmaten "acdress for Communication ‘FlavRec/ Door Block No ‘Name of Premises Bung Vilage Read'Sveet Lane Pest Otfce ‘Area Loclty Taluka Su>-Dviion oan) iy Dist State / Union Terry {L}2etephone Number & EmalD detais County code Area/STD Code “Telephone / Mobile eurber L I 21811 [5[21 Sey) ] emai | Cueto oxefaneasdSinic cee (Tt0AAoHAaR number it alotea) ae Reni Het 1 { (_J 1 Menton other Permanent Account Numbers (PANS) inadvertently allotted to you PANY PAN 2| o |PAN 3 jean af [TTT TT 12 Veriton we (ASHI Co)

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