__________________INFORMATIONS FOR APPLICATION OF PRAN________________

(Filled in the form in block letters only) All informations are mandatory. No over writing and cutting is entertained.

1 Name of the Employee

2 Date of Birth
3 Date of Regularization
4 Date of Retirement
5 Aadhaar No.
6 PAN No.
7 Village:-
Post Office:-
Permament Address
Police Station:-
District:- PIN Code:-
8 Village:-
Post Office:-
Correspondance Address Police Station:-
District:- PIN Code:-
9 Bank Account No.
10 Bank Name
11 IFSC Code
12 Valid Mobile No.
13 Mail ID.
14 Father’s Name
15 Mother’s Name
16 Spouce’s Name
17 Spouce’s Date of Birth
18 Nominee’s Name
19 Nominee’s Date of Birth
20 Relation
Documents required
1 Voter ID Card (Xerox)
2 Aadhaar Card (Xerox)
3 PAN Card (Xerox)
4 HSC Board Certificate (Xerox)
5 Appointment Order (Xerox)
6 Photo (3.5” x 2.5”) 1 copy
7 Cancelled Cheque 1 copy
8 Full Signature on a white paper

Certified that the information furnished above are correct to the best of my knowledge and I have submitted all the
required documents.

Signature of the Employee