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

Only ‘Individuals’ to affix Only ‘Individuals’ to affix

recent photograph recent photograph
(3.5 cm × 2.5 cm) Permanent Account Number (PAN) (3.5 cm × 2.5 cm)

A S P P D 5 6 4 7 K

Signature across this photo

1 Full Name (Full expanded name to be mentioned as appearing in proof of identity/address

documents: initials are not permitted)
Please select title, v/ Shri
 as applicable Smt Kumari M/s
Signature inside the box
Last Name / Surname D I X I T
First Name K U S H A L
Middle Name M U K U N D B H A I
Name you would like it printed on the PAN card

2 Details of Parents (applicable only for Individual applicants)

Father’s Name (Mandatory. Even married women should fill in father’s name only)
Last Name / Surname D I X I T
First Name M U K U N D B H A I
Middle Name B H A N U D A S
Mother’s Name (optional)
Last Name / Surname
First Name
Middle Name
Select the name of either father or mother which you may like to be printed on PAN card (Select one only)
(In case no option is provided then PAN card will be issued with father’s name) v/ Father’s Name Mother’s Name (Please tick as applicable)

3 Date of Birth/Incorporation/Agreement/Partnership/Trust Deed/ Formation of Body of individuals or Association of Persons

Day Month Year
18 06 1988
4 Gender (for ‘Individual’ applicant only) v/ Male Female (Please tick as applicable)
5 Photo Mismatch
6 Signature Mismatch
7 Address for Communication v/ Office
Residence (Please tick as applicable)
Name of Office (to be filled only in case of office address) G L O B A L T E C H C O N T R O L
Flat/Room/ Door / Block No. 8 9 8 / 3 / 3 , B E S I D E S D A Y
Name of Premises/ Building/Village L I G H T L U M I N A R I E S , N
Road/Street/ Lane/Post Office G I D C E S T A T E , M A K A R P U R A
Area / Locality / Taluka / Sub- Division
Town / City / District V A D O D A R A
State / Union Territory Pincode / Zip code Country Name
Gujarat 3 9 0 0 1 0 INDIA
8 If you desire to update your other address also, give required details In additional sheet.
9 Telephone Number & Email ID details
Country code Area/STD Code Telephone / Mobile number
+ 9 1 9 7 2 3 0 6 7 2 2 3
Email ID kushaldixit1988@gmail.com
10 AADHAAR number (if allotted)
Name as per AADHAAR letter/card

11 Mention other Permanent Account Numbers (PANs) inadvertently allotted to you

PAN 1 PAN 2 PAN 3 PAN 4
12 Verification
I/We , the applicant, in the capacity of Himself do hereby
declare that what is stated above is true to the best of my/our information and belief.
I/We have enclosed (number of documents) in support of proposed changes / corrections.
Place Gujarat
D D M M Y Y Y Y
Date Signature of Applicant (inside the box)
L-13169354851
 INSTRUCTIONS
Please refer the following steps after Application Form is downloaded and printed.
1. Once the Application Form is downloaded you should print the same, attach your
recent, coloured Passport size (3.5cm X 2.5cm) photographs on the prescribed boxes
in the form.

Kindly Sign Across the ‘Left’ photograph (signature should not be done on the face).
Sign beneath the ‘Right’ Photograph in the box provided.

2. If the applicant is unable to sign and choose to put a thumb impression, then the same
should be attested by Notary on the form. Make sure that Thumb impression or
Notary stamp should not be on the right photograph.

3. Once the form is duly signed and photograph is attached on the form, it should be sent
along with self-attested document proofs for Identity, Address and Date of Birth by
Courier/Speed post to the mentioned address i.e.

The Manager,
PANIND Services Unit,
No. 5, Site 4, Vikaspuri,
New Delhi-110018
India

4. The PAN Application process would start once we receive the duly signed form along
with all the document proofs.

5. You would be intimated by an email your Coupon/Ack number after receiving the
signed application form along with ID Proof, DOB Proof and Address Proof.
 Annexure -B
(Certificate to be used by the Employer on the letter head of the organization / institution under sub-rule (4) of
rule 114 of the Income-tax Rules, 1962)

(Affix same photograph as

affixed on PAN application
form)

(To be attested by issuing authority with his/her

signature & rubber stamp appearing half on the
photograph and half on the certificate)

It is hereby certified that Sh./Smt/Kum… ………………………………. son/daughter of

…… ………………………... is employed with us since ……. . He/She is presently working at
the following address of the organisation:-
Office Address ……………………
……………………………………
……………………………………
The residential address of the applicant as verified by us is given below:
Residential Address …………………………………..
………………………………………………………….
…………………………………………………………
Registration Number of the Company/Institution etc……………………………………….

PAN of the Company/Institution:

Details of the Individual issuing the certificate

Full Name:

Designation:
PAN of the Individual:
Office address with location:
Telephone: (Signature)
Mobile: Office Seal

Date:

Place: