[Application Number! LIVEN INI |>2rnen:sctsones SOT 125323131156 T PYOOSBTSTES JT 2 Ipayment date: [11/04/2023 12:53:21 ————— J Amount: i Rs.:107.007- ]Appiication Date:[i 1/04/2023] User Nam¢ ] Application Source:|EWALLET - A - CSC E GOVERNANCE SER PAN Gard Mode! cz physical PAN and 6-PAN Card |Application Mode: [Physical Application Request For New PAN Card Or! And Changes Or Correction in PAN Data Permanent Account Number (PAN) t[o[o[Plo]ela|s[aly Please read Instrucions 'W for selecting boxes on laff margin ofthis form qr a eer 6 a cpoal [i palvere teens ene a emeioa ire Please selec we, Lo | asappicable. ‘Shri Smt | ¥ [Kumari Mis Spaweta ha reese First Name TIH/TIRIU|KIUIM|A/RIAIN anes Name you would lke it printed on the PAN card DI I KIS|HJA]_|T[H]1|R[U|K|U[M[A|RJA[N icabie only for ind latory, Even st C1? Peis ie Lis Name /Sumame Frattome Mite Name [ I Mother's Name (optional Leet Nae /Suneme [ I FirstName [ I +4 f +++ Mite Name [ f I | Select the name af ether ther of mother Wich yOu may Te obs pte on PAN car oy (incase no opon is provide then PAN card wl be Issued wit father's name) [Fates tre mauve wnly) R Mother's Name (rneret er ursat Day Month Year Go] [fz] [2[ofoya 3 Date of Bith/Incorporation/AgreementPartnersh Formation of Body of naividuats or Association of F Els Gender tr naviuaappicant ony) [—] Mae [H rrenagenderseutscins [YZ] 5 Photo Mismatch J] signature Mismatch [7]? Address for Communication ¥ |Residence{_ Jorrce ee ik appa ‘Name of Office ote te nc ton etn FlavRoom Door! Block No. 3)A Name of Premises) Buisingivitege [STAIN [D[H [1 ly [1 | [s|t[RlelelT I RoadStret/Lane/Post Ofice Klaleh [Plalrit hi | [Plolsir ‘Area / Locality /Toluka/Sub- Division [T [1 [R JU [C [HE [N [G [OD [E Town City Distt Ila Ila [Ik [a [o State Union Tero Pincode /Zip code Country Name {TAMIL NADU 6[3|7/5]0] 3] INDIA [1 sttyou desir to update your other adress also, give required deals nadetiona sheet. [E[oreiephone Number& emai iD detaits Caiysole AreaCode phone / Mobile number on 4[2[8]4[5|4]2]2 Email |rkarthiku@hotmall.com. 10 AADHAAR number (alloted) 7[ 9141 4 221414] Gir lala Nome as perAADHAARetetard TT Ik IS IMIAT IT] IM +1 Mention other Permanent Account Numbers (PAN) inadvertently alloied fo you pan Pana] ans] anal[J 22Verteation we [DIKSHA THIRUKUMARAN |; the applicant, in the capacity of [HIMSELF/HERSELF de hereby declare that whats stated above Woe o te best of mylour infomation and bei. (Me have enclowed 2] (oumbr of documents) in suppor of proposed changesfcrtctons Place |KALIPATTI \ L DomMyYyyYyY tr. eee Date |1 {1 ]0/4/2/0|/2/3 Signature Left Thumb impression of Applicant (inside the box)nt Form Aadhaar hol. Biometric and/or OTP based eKYC and Aadhaar Authentication PAN/ApplicationNo.: Q008974177 Name as per PAN card: DIKSHA THIRUKUMARAN ‘Aadhaar number: XXXX-XXXX-7741 Name as per Aadhaareard: | D|KSHAT M Declaration: I do hereby confirm that the Aadhaar given above has been issued to me by UIDAI. As part of process, the Aadhaar/eKYC data may be used only for the requirement of PAN allotment. I state that I do not have any objection in authenticating myself with Aadhaar based authentication system and I hereby provide my consent to use my Aadhaar number, Biometric and/or One Time Password (OTP) data for authentication for the purpose of fulfilling the requirement under PAN process. I understand that the Biometric and/or OTP provided for Aadhaar authentication / eKYC data shall be used only for authenticating my identity through the Aadhaar Authentication system for the purpose of only PAN allotment process. This is further acknowledged that while submitting through Change Request Form in PAN data. If in case, Aadhaar is not linked with PAN then through this process Aadhaar will not be linked with PAN i.e. will be used for authentication /eKYC purpose only. I understand that complete security and confidentiality shall be ensured for my personal identity data provided for the purpose of Aadhaar based authentication. Ie spel ¥t 11/04/2023 Signature / Thumb Impressionore OHSw sipenmsid ‘ype, en renb Enrolment No, 2043/88801/03550 ® Dikgha Thiukumaran a or 8 io tartan GAwoMul stREET kaureatnipost) ‘avora0%s i seas Mt vi s100125 2. Huse 24HIi) stoi / Your Aadhaar No. : 7914 2211 7741 SNH - EnGTyom wahgefer sHend 88 cor Bone Diksha Thiukumaran joomns Female 7914 2211 7741a . 4 => Aw. Eo ae XAOHAAR HEU = ayn) son _unensPibsnen one) GgqufNowsG 91600 = sencuinar scien Benemuspond epexd = pBiuGSAS Cansrenayd Chis Sybase Bemsteturg UaUTODLHe Apuubesieder ysidas Goveingd INFORMATION ‘= Aadhaar is proof of identity, not of citizenship. = To establish identity, authenticate online. "Children on aitaining 15 years of age need to update biometric information. = ond pr WYAPpw OsdgugurED. BaGkerngHo one wpb sys en Ceaser uUdUGSHS Aancton asin ‘= Aadhaar is valid throughout the country. = Aadhaar will be helpful in availing Government and Non-Government services in future. cee Shawn sree a ul STREET. had KALIPATTKPOST), ee Notasor arom vet ssemingne ope Matesarcram, Namal, ‘seenesom prota. 3p pre Teuchegoae Tam Nass = ens 7914 2211 744 z ba