‘Applets Nama | SARLASRIWASTAY [aren rt [BARLASRIWASTAY — Fathers Name [ecromnetatied Voters tans tt mewoned ‘Date of Birth! rz 02 1948 [Communication Addrase State MADHYA PRADESH (23) alana. [evaarr 33980 ‘Banal 1) _ [STUDENTZONEZHO OMA COM ‘Proof of kdentity JAADHAAR Card meved by tha Unique Kiencation Author of in Proof of Adéress, [RADHA Card eve by te Unique Wanifcaton Aron ofa Proof DOB ADHAAR Care weed bythe UneRe Went Axon ln leromatac: comrmrirasn mie canes PAN apileation foo 291.00 [Branch 10: 86003 sete aApplication for Allotment of Pormanent Account Number (Inthe case of indian Citizans/Indian Companles/Entities Incorporated in India! Unincorporated entities formed in india) Se tuaie i Assessing officer (AO code) Area code AO type Range code AO Ko. ae rp Je tw = 3 [4 Sir, Ue hereby request that 8 permanan acount number by alot to malus. we gre ow necessary parvulars: Please select tte, |v’ ]3 applicable Lae Name /Suname Fret Nome 2. Abbreviations ofthe above name, as you would eet to be printed onthe PAN card fefefRicik] [sie by Ne rTIs [ T T I | I 2 Have you ever boon known by any cthar name? —[_| Yow (please tick as appticabte) "7s, asso ge matter nam Please seloct ttis,| V’| as applicable Shei ‘sme. [Kumari [_]Ms Las Narre / Sune g Fiat Name Q Mao Name 4 Gender forindividual applicants only) |__| Male 6 eins ot Prone aopcabl nt fr nda w Sos andy wor pa PA yg te rac yourmetw oy? Ys ]Ne|_ Jr en Tyas pose Wk matirs one fbs eoponsse en eee Easers eres Sartre Yee ete meee to career zee eve mentee Ot PhO oy) Lost Name (Surare '¢) oh 6 ay eel Fit Nome =uekis T Middle Name Rizk RST TTT a Motes Neme (optional xcept where mothers single parent ene PAN ie Shree cn) Lat Narva /Surnam iol Sn de ry Fret Nane cl I I [ Miia Name eee ar Toy fetid Sala the spe cf ete Tha BGP wich You Tony ea oe rad cn PAN cae (Enact one Ont [peeter nave” [ [pears pane Plame tek pte) (In case no opbon is proviced then PAN card wil be issuec with father's name except where mather is a single parent and you wish to apaly for Pa by turn mare ert oy) 7 Adress Residence Aaaress Fat) Roam"! Boe No Name of reno Bung / Boye Road Set LanePos fice Are cl Tkal Sb Doon Tn iy Oia Siaie/ Union Teory MP SAD? Renesty “satel ail [Weg fos tice Addrves Name tefce FRat/ Room /Door Block No. ‘Name of Premises / Bulking / Vilage Ros Steet! Lana/Post Offce ‘Avo! Local (Tauka/ Sub Dwison “Town I Ciy Distt Stave / Union Terrtory Ld‘Telophane / Mobile number apetihisiasL LT) [7 Jes patente 1 coverrment rand undiacedtrnty [__]Comary [F)renmerehip Fim (C7 Aasociaton st Person edyotinekaduts —[_] Local Aumont [Cenc cat Persone [[] Urasa Lot Peer company, firms, LLPs ste) ‘as per nection 139AA 1 13. Source of come LD soley J income trom Banas Profesion cccneenPretensen ode [_L_] T tncome trom House rroneiy ‘1A Representative Aseassee (RA) Full name, address ofthe Fepresonintve Aasausoe, wn 6 ‘buen given in the column 1-13. Please select, [V7] LL copia ins Fer cade: Rerinamucions) [__] heaee tom Ofer seuss LE Grene smcnaio under te cre Tax Actin rpc te pron, wrote PaaAaT® 7" as apatcabie ull Name (Full expanded name :intols are not permite sm. Kumar Feneraniisa(Z]eemecte []80 Leet Name /Sumame | rutone ie Na Aadress Flat / Roam / Doar Block No, Name of Promises /Bulding! Vilag® Road / Street LanerPost Ofe= ‘Ars / Locality Taluka! Sub- ONvison “Town (City /Disrct State / Union Tertiary Pincota Peres 2s Documenta subratted as Proat of Wentity (POD ax pronto adress and pene refer to tm sours (os epeciiad in Fale $34 of poner A Arnau 8 BATIONY Care BR 16 vweL_S. tar do hereby decare thet what i ated mbove Is U2 12 | ppMMYYY¥ Bbblosiadely Pisce ‘proof of Address (POA) and vcr waned (SAE CHRIS] Proof of Date of Birth (DOS) proof of entity. 1T: Rules, 1982) for fot ‘used wherever sppcatlel (wees | the applicant. in me capacity of the best of myicut information and bebe. ae a ee Te Thom Prpression ot _Amicant Gnsite te box) ‘Signature Let‘THIeri PHY Enrolment No.: 0620/43011/18714 | ica ior ‘Sart Steeactav i WOlwalapnisad ronments SST STE APH / Your Aadhaar No. : 4866 2748 5561 Vid 9138 8166 4533 4217