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18t1
CES NDIA LII\NITED
2657 5547 0410
)AN CARD MODE:Both cal PAN and e-PAN Car.l licatron N{ode
Form No. 49A
Applicaiion tor Allotm€ot of Parmanent Account Nurnt ar
lln the .ase of lndian CitizeE/ In.ltan C.mpanles/ EntilGs incoryoraH iE lndia,
unincoryorared €fltiiies {ormed in lndial
s.6
p! ro av.d mbk .. rEe Idr@ e a.sntaoyi E
Rulo 114
inalffum! nd ei4r6 b€roE flrsE rp ri. tn
As6i$ing orficer (Ao c!de)

3i B G t=1- Irl-rl; 2

ri'i: a,..:: _.
ad.\*2r,
1 Ful Na rr iFui crpa.ded namo to be,rcnroncd as
shi
Last Namo / suftame o R o N
B B U L L I t1
2 Atrbrevlatlons of the abov6
B B U L L o R o N

lll
3 Have you ever
lf y6. Fl6r liw
be6r knowr by any olher name?
that other name
n t( (plcase rick as applicable)

Lasi Name / Slr.ame

4 Gend€rltor hdivldual applicants orlyl x tr T.ans!rende. (pteaserick as apolicablc)

5 Oateol Bi.lh/lncorporationlAgr€om!nt/Partnership or Trust Ogedl

rormation or aody otin.lividua,s or.sso.irlLoo of Pcrsons 1 2 0 2 1 9 6 2
6 Details of Pa.enls lrpplicabie only for nrnividLat apptican!s),
Whetlrer mother s a s ngle pa.ent and you w5h to apply Jor PAN byturi\ish hg the narne oryolr mo$er o.jy? yes
llyes peasel D motheis name inth. appropralespa.e provi.l.d beow.
r (p case 1!.i( asappli.abre)

Falhers's Name (Mandatory except whe.e mother is a

o R o N
T o
IMothers's Name (optional erceptwhere horher is a singte parenr and PAN is by lurhlshing th6 name olmother

( n.ase no opilcn s provLded then PAN.ard wrlb.lssled wrh iathers.afle exceptwhere moihe.is a sing. parentand you wtsh ro appty for
PAN byfln:shing name ofthe motheron y) x ll.rihcrs N;m.

0 0 0 0
Flal / Roofi I Ooor / Block No.
Nahe or Premis6s / Bulldirc / Vllase
D K S H N T K R
Road / Sheet / Lan8Post Otrw D K S H N T K R
Area / Localily / Tatuka/ sub, DMstd L I U R D U R
L I U R D U R

,WEST BENGAL 7 3 6 1 2 1 IND ]A

Nast€ of o,fioe
F.lat / Room , Door / Bk ct l.[o-
Naae of PGmis€s / Buildins / \rilbqa
R^ad / sheat / Lan6/pcl a}flift
 A.6a / Locrlit / Tallka/ SUE DMsion

I AddressforCoomuri@tion x lPlease tick as.Fpr'cabtei

I Telephone Nuober A Email lo detaits
Counlry code Area/STO Code Telephone / l,tobile nlmber
t I I ! :1 L

mmadhabl il.com
l0 Status ofapptloani
Plea* select shtus,

Hindu lrndivided tumily

tr Associalion of Pe.ses

[r,*r" E Body or rndividuars Arlilicial Juridiel PsMns linrited Llabiliiy Pa.lnershlp

11 Reqislration Numb.r (Iorcompany ri.tus, LLPS 6rc )

persor, who is required to q(oteAadharr nunrbe,Tbe EDrolment lO ofAadhaar applicatioh form:s

a
Prease mention yoor AADHAAR .rmber {jf Blloted) 2 l 1 l 1 I I 3 a
-l
1IAADHAAR number is not alloited. pleas€ meniioo rh6 enrolme.i lD of Aadhaar appticatioE fom

Name as per AADHAAR letter/card o. as per lhe Enrolment lO oiAadhaar applicaijon form

B B U L L o R o N

13 So{rce of lnconie

[ ,n*." oo* r,o,". o,oo"n,

ln@me tom Blsr.ess / Proiession Business/p.ofesslon code
)(
f,
n [For code Reier instructions] ,n"o." oo' o,no,,.,ou" !
lrl Represenraiive dssessee (RA)
Full name, addrcss of lho RelJresenlalivo Assessee, h'tro is ss*sible under the ln6m6 Tax A.1 in respect ol th€ peMn,
whose padbrtars have
ben giv€n in the corumn 1-13.
Fu[ Name {Full expanded name : initiats 6re rot permtneo
x
o ) o
T
l,liddle Name

Flel / R@m / Ooor / Btock No. il L 0 (l

Name or P.emis6s / Building / Villase s :l 1 il (

Road I Srreet / Lane/P6r Ofic6 il i 1 K
Areq I Locglily / Talukar SUF Dlvision 1 U

- 1 !l U

WEST BENGAl, 3 n 1 2 1
15 Oocuiienrs srbm rted as Pr.or ol ldentily lPOl), Pr.ot ol^ddress IPOA) .nd proof of oare of Birlh
{DOA)

rs n

r: r(ri.i.,-_.,r !. : r
as prool ol daie ol binh

IPleese €rer to the insrtudtns (as spe.iied in Rulo 114 of l.T. Rules, 1962) Ior lisr of m.ndalory .edifiEd doclmenb ro be submi(€d as
IAnnexure A. A.n6xwe B & Annexue c a€ lo ba used wherevef appliebtel

. iheapplacanl.ln the capac ty oi

do hereby declare tftat whal ls staled lbove is rue io lhe best of my/our intomaiton and betiet

HIN PATKAPARA

1] D L,I
a{*ve*?f I
I E 1 n 20 2 2
signature / Lefl Thumb lnrplsion of App,icanr {inside rhe box)
#
e5 ;A\g,

-s-l-<g !?FF-K
of lndia
s-IF-rl,iXJbi eF E / Enrollmeni No.: 1215113067/02087

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