‘errors cs w-cevonraseses UTADA NL MNT Request For New PAN Card Or/ And Changes Or Correction in Permanent Account Number (PAN) H2KPP2T36N Please read Instructions 'h’& for selecting boxes on let margin ofthis form, eee yore [ “.Full Name (Full expanded name to be mentioned as appearing in proof of Identityiaddress Please selecttitle, as applicable [2 shri CJ) smt (Kumari Os Sigaare Le Tne Repression oT ‘Aopleart (nde the bo) Last Namesurame rather a ade ame Nae You woud pried on the PAN ar [LRAM PRAKASH } 1 2 Details of Parents (Applicable only for individual Applicants) ‘Whether mother is a single parent and you wish to apply for PAN by furnishing the name of your mother only? Yee OC Nol Iyes,please fll in mother'e name in the appropriate space provided below. {please tick as applicable) father’s Name (Mandatory except where mother is a single parent and PAN is applied by furnishing the name of mother only) Last Name/Sumame ‘SINGH Firet Name BALVEER Midale Name Mother's Name (Optional except where mother Ts a single parent and PAN Is applied by furnishing the name of mother only) Last Name/Surmame First Name Middle Name ‘Select he name of eter Fatnor or Mather which you may Ike fo be printed on PAN Gara (Select one anlyp In case no option is provided than PAN Card willbe issued with Father's Name. Fathar’s Nama Mother's Name Oo (in case no option is provided then PAN card will be issued with father's name except where mother is @ single parent and you wish to apply for PAN by fumishing name of mother only) 1 5. bate oF BirewincorporationiAgreement Partnership or Trust Deed! Formation of Body of individuals or association of Persons Day Month Year ‘O1/01/1969 Oo ‘4. Gender(for individual applicants only) El male Female Transgender 5. Photo Mismatch Zc signature Mismatch 7. Address for Communication Residence D otnce Ft Roe Dao eke Name ofPenses Big Vege] Re Stee anos Ofee | | Slate / Union Terao PIN Goa 1B Gok nko Name (uttaRAKHaND 263182, ul INDIA. ] Ifyou desire to update your other address also, give required detalls In additional sheet ee Telephone / Mobile number County code ‘Axea‘STD Code 3% 9473865427 Ema iD 1DS181565@GMAIL.COM [Fit0. Please mention your ADHAAR number (alloted) [RRRRTES J lame as per AADHAAR etrcard | lan PRAKASH IZI"1. mention other Permanent Account Numbers (PANS) inadvertently alloted Yo you pan [ GBOPP9O7IH PAN PAN PAN 42. Verification we [RampRAST T]he eppticont, inthe capacity of do hereby declare thal what is slated above is rue tothe best of mylour information end belet boli. We have enclosed enangesiconracions [2] (numbor of documents) in support of proposed Place ‘GADARPUR Dh Yv¥¥ Date Sinatra TaA Thumb inpresson oF18, Other Address : Name ot omee Flat Room / Dor / Block No Name ot Premises | Buleing/ Vilage Road Street / LanePost Office ‘Area / Locality | Talukal Sub- Dvsion Town / Cty District State / Union Terntory PIN Code ZIP Code Country Name ‘Signature /Left Thumb Impression of Applicant (inside the box)