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AN CARD MODE : Both physical PAN and e-PAN Card
Fcrm llo.4$A
Application for Allotmen! of Permanent Accoufit l,lumber
0nlY [!n the case *if lndi*n Citieensi lndian Companies/ editie incorporeted in lndia/ On?y
lrlri1t,s_li)lj Uninsprpf,ratsd entitier formed i* Indial 'htji!idr*ls'
ii i.ifix rar.nl 'l tb &fnv e*afil
Sre Rrlu 1;1.
phbto$raph
piticll':}$e?ll
ic ffvrli, si*ial,rrs, a,lF$It{ tr}llffr,{ lir} .lic(t^\ii1t1\!in}in},it)cli*n$ ir J ,t) irr:pi{ri hrl.rt ril.-r uF irn rn"E
i.'J.lt at: x {3.i cn x
2-5 *t1!
Astes.sing officer {A0 code}

EBUT'fiilI,

*ir, tlV'le her*by l'e{r.i€sl [hEt a PsrnTanen{ J\e**unt r.iumfj*r be allotl*d to meius.
l'Ylc qivc b':low ncc(tssary particular*.
I Fuil Hame {Frll ex;:andad namc to be menticned as in proof of dccurl1entsi
lalei,$e se:ect ti**,lf *, applicable l_l gnrl

L.*sl lla*re / $.urnanre

First I'lame

h';i#ti[x Nt,rn*

*.lave
li yer. ple=se
y*u ever lresn lrrown
r-Jivs
5,
lhal oih*r ,1fime
any *lh*/ $aftys?
E*o {plear* tick as appliqablei

fi
P:eust, sel*ct trtle. ly' as appJ;eirLrle

La:t Nartr* / Sumame

i?Ilftitig i\:IllH

Gaxder (fcr lndividual applicants on!y|

gay Moarth
$ Sate ol *irth/lncorparationlAgre*rnont/Partnarship or Trust Seed/ I ' -l
Frrnraticn of Body of individualr nr aseociation cf Parsone 11 0i Ls-i-l I
*ei*ils of psrents {applicable only for i*dividual applicanta),
Whether mother is a single parent and you wish to appiy for PAtil by furnishing the name of your mother only? Yes *o (please tick as
lf yes, please fill in motheis name in the appropriate space provided below.
l-l f]
Fathers's Name (Mandatory except where mother is a and PAN is the name of mother
L;rst [Iafie l*urname
fiirst Narne
]r,ti,-jrt:erda'rre I I i I

Mothers's Name (optional except where rnother is a

"L$-it$j:,?pfltgu.!f [y11irhins lhe name of mothel
1-asl l4amr: I Burname

fi.$t t{ame
?:l.i..trd1e l*a{ne
Sel*eJ thq n;rnre of*ilherfalfrer ilr ft\t1the( y{A way like lrl l,e ;;rinleti orr PAN canJ {)*ttrl t,tc o*t.t.t
(ln case no option is provided then PAN card will be issued with father's name except where mother is a single parent and you wish to apply for
PAN by furnishing name of the mother only) f ..,,n*,., rrintn"r., ff nu** f *n,e
f] rrtnv ri,:t 4t nt,/i,ilht(r
Address ,
Recidence Addr**s
rrSi , r{oorY} r uoor / Hloct( ll0.
ilJa,lr* *{ Frerfli*es / BuiidiilE / Village
11':.ac ' ;ttreer i LnnelPosl Oifice
Area ! Lacalii't ITalukal Su*- ftivisi*n
Ta'"{ri 1 [itY I District
5till0 I un,$r1 lf,rfrtor'y' Pinfi*d* I ?ip corje fiounlry Name
lit
*ffice Address
Nanre r:f oflire
Flat / Rooirl / fio*r I Btoak No
l,lam* cf Franris a* i &uildit'tg1! Villag*
s
 Aroa Loc;lirt'y' t Talukal Sub- Divisron
,'

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{olvn ully; utslnct E1-;TA{BT^"lD

i c uJARAT i3 B 2'3 3 o: I t ND I A i

S Addre$$ fer C*mmunicatiorr I Resioenc* l7Iam** (Please tick as applicable)

I Telephone H*mber & Email 1D details
C*untry c*de kreal9Tb *rs,3* ?*leFhofle I Mobil* n*m[:er
' 1 r i '1 "l I I I
i r : I":
lolr I lolr I I I i : l7lsl7;318,616,414:31, I

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tn:air ill ll mahavi mail.com

10 $tatus of applicant
f-1-1
?leaz'.* *;el*el *lar.u*,
ld i"a$
a1plicav*la Governn:ent

1r:rlividuai
[ *,n,lu unctivideci ,an1i]y n*,r,roun, I Perlnerst':;r rirm Asr.ociellon al F *r sors

lrtlsts Srri',r of i ndivirlual* Lot:al Aulh$tily f]nrr;rr",ai Jundical Persons linritecl Liabrlity Parlnership
f]
11 *ogi*tr*tiorr I'lunrbcr {for *ompany, firme, LLPs etc.)

I c [-7lT;
u l-:;-7]Fi u- r i H i T l A-,vl-u- j-lT:,_fl7f, T,_,--il- l-::l_-l
13 ln Cass cf a person, who is r*quired to quoteAadhaar lB olAadhaar ap..plfcatian form a* per section 139AA
numberffhe tnrolrnent
flet$e menli*n yoUTAADHAAR nurni:er (il all*lted)
ItAAilHAAR nunrb*r rs not alfcttr:d, please lrt:r-rli*n the enrolnrent lD af Aauhaar applirxti*n f*rn'r

I,alns *s per: AAD|1AAR lett€r.icard .r{ ES irer lhe f;nrolmtjfli In of A*dhear *pptriealinn lornr

13 Scurce of lncome Please select l7 ' ,u Elpplicable

I s*'*'y f ,n.o** irnrn ll*u*e prcperty f o,u in*0rxe f canitarc#s
I I lnc;rl.cl fforn Bdcincss i Profrjssron Business.rFrofr:ssron codc
itt
[For Codr: R*fer inelructians] p ,n*o** frsnr Other sourcq.
14 Bcprasefttative Ass*sse* {k&}
FLrl ilan]e ad.lressof theRepreser'rldtr'./eAssessee whoisa::sesljb;eilnderthelncomeTaxActiftrespectof theperson.whosefjartrcularshar*
he*n 5;ir,*n in fiir* *rllufitn 1-13.
Fult Name (Full expanded narnc : rrritials are not permitted)
Pree:ie select titt+ I /; as appiicab,e

Last Na:]ie I Sr-rrnamc

Firrt a{{rme
MiCdlr, Narne
Addrss$
Fla{ J l4r:r:m I A**r I Block No.
f'.iarne r:f Fremises J Buitding lVtlta1e

i{t:ar: i Strett r LarreiPost 0iTic*

tu'*a i L**alily I Taluka/ $ab- lliv"is.l*n

1-*wn i {lity / iljstrict

St*te / Unitn Terill*ry Fineod*
'15 B*currrents submitted as Praof cf lden{ity {FSl}, Proaf of Address {P*A} and Froof of Date of Birth (DOB}

li\ J* hare enclase* *s praoi r:l idenlity,

itx *rrsal *{ *rtlrlren* 6n4 i Ke9lSIraIlOn CerilllCate ISSUeO Dy ;1 as pr*ut rf rlate of hir'ah.

fAnri*xr,:r* A" Annexure * & Annexar* * a{e l$ he ils*d I'tfiereyer applicaLi*j

KIR ITKU MAR tAti TBHA| pATEt- - -------', rhe.:ppt;cant

16 1,'/,'e i
! i,r the capacily or IPARTNER
r.1* h*r**y rJ,,cl{)r* thatr whi}t i$ $tnlerj ab*ve is true t$ the h*st of myirrur inf*rnrntinrr and beiirf.

Fixce iAHMEDABAD sl

DDlvJldt/YYY
Dz:te :
lF.q]52ir-!_E Signature i Lett Thuml: lmpre*sion of Appli{snt (inside ihe buxi