‘Application Numbers AQ87@00537 TNLQOU) INN | rrr sete ee ‘4031130425 192867 / PYO122609845 PaymentDate: (31/01/2024 Rs.107.00/- |Application Source: [EWALLET - A- CSC E GOVERNANCE SERVICES INDIA LIMITED JApplication Date:[31/01/2024 _| User 1a:(2715624 10018 Juser Name: } [PAN CARD MODE : Both physical PAN and e/PAN Gard ligation Mode - Physical Application Form No. 494 Application for Allotment of Permanent Account Number lin the case of Indian Citizens Indian Companies! Entities incorporated in Indial Tos matte, ess olin a accion netomat ramets ng pret ‘Assessing officer (AO codo) ‘Area code ‘AO type Range coae AO No. sTu[tlw 1 9 [4 Si, IWo hereby requost that a pemanant Account number be alloted Yo mais Su or ahi lie give below necessary pariouars: 1. Full Name (Full expanded name to be mentioned as app ing in proof of identity/address documents: initials are not permitted) Please selec ite, [¥/]as applicable Shai sme Kuma [v] ws LastName /Sumame ARIVAIN| [B)IIKJE| |S/E[R[Vi1 [Cle] [cle|N|TIE/R First Name T 1] I Middle Name I l LI I 2 Abbro 5 you we AIRIY|AIN| BII/K/E) |S 3. Have you ever been known by any othor namo? tyes, please gh that ther mame {please tick as applicablo) Please select tie [¥/] 8 applicable sna Last Name Sumame First Name I [I | | ice Name I CI ] 4 Gender (for individual applicants only) 5 Date of Birthiincorporation/Agreement/Partnership or Trust Deed! Formation of Body of individuals or association of Persons {5 Details of Parents (applicable only for individual applicants), Mate Fom: [Fitransgender (ptease tick as applicable) \Wnetrer motors sre parent ad you wsh 6 abe fo PAN by Turing he name of yourmeihar oly? Yes] No[_] aso ticks apptcaba fy, please filin mother's name inthe appropriate space provided baiow. Fathers's Name (Mandatory except where mother is Last Name / Sumame 2 single parent and PAN is applied by furnishing the name of mother only) First Name. Mice Name ‘Mothers's Name (optional except where mother i ‘single parent and PANis applied by furnishing the name of mother only) Last Name /'Sumame First Name Miaste Name I ‘Select the name of either father or moter wiveh you may ike 10 be printed on PAN card tat nr at (ir.case no option ts provided then PAN card wal be issued with father's name except where mother's. a single parent and you wish to apply for PAH by tumshing name of te mother ony) Father's name Mother's Name dence) 7 Address Residence Address Flat Room / Doct Block No Name of Premises /Bulcing/ Vilage Road / Steet /LaneiPost Office ‘Area | Locally Taluka! Sub- Division Town | City District State / Union Toxiory Pincode Zip cove Country Name Office Addross Name of ofica| Flat/ Room / Door / Block No, Name of Promises Buiding / Vilage Road /Sireot/Lane/Post Ofies RIMIA|KJA[R ‘WIN N.‘ea Locality Taga ub-ovson— [MLAINI [ATL [DIAL T ‘Town City | Disbict DIAIRRIAIN|G| I I ASSAM 7a] 4] 71716 TN DTA 8 Address for Communication Residence (Pleae tek as apptcabe) 8. Telophone Number & Email details County cose Areal STD Code Telephone / Mabe number sil] GL @[o[7[2[=[7]o[s[o]7 emai [evive@@gmail com 10 Status of splicant Posse slot sta, [¥]os sppcable | Lircividuat — ]ptincu uncviced amity [_]company 7 Pacnership Fem [association ot Persons Corns Eero ]tocaatonty [pt rical Parone med iby Pane 1 Registration Number for company, rms, LLP ete) els[?|-beVelol2i2|-l2121- le P 121m Case ofa person, who i required of Aachaat application form a8 per section 1394 Pease monn your AADHAAR number fale) ITAACHAAR numbers not alte, please mention he enoiment of Aachaaraplaton fom Name as perAADHAAR letercard of pero Enrolment Dot adhe appieaon fr 12. Source of income Pease seen, [¥/] as aplicable LY satay Income trom House property LL] capitat eains [Ll scenaien/Gudnase/tiiae elntamaien ti 14 Representative Assessee (RA) piece or re oR eset fans pa cepa ates tty Dnien I [For Code: Refer instructions} the Income Tax Actin respect ofthe person, whose particulars have Proase select tie,|V/]as applicable [7] sori Last Name / Suname aloir[ | First Nome. Middle Name Address Fiat / Room / Door / Block No. Name of Premises / Building / Vilage Road / Street/Lane!Post Office ‘Area Locality / Talukal Sub- Division Town / ity / District State / Union Teitory SS AM 7ela[a 415 Documents submitted as Proof of kentity (PON), Proof of Address (POA) and Proof of Date of Birth (DOB) We have enclosed { Registration certificate ISSUET | as proot of i lontiy, [Registration certificate issued by fegistration certificate issued by 1 proof of address and [Pease reer to the instructions (as specified in Rule 116 of 1.7, Rules, 1962) [Annexure A, Annexure B & Annexure C are to be used wherever applicable] |SUKURALT 16 Wwe| 28 proof of d «the applicant, in the capacity of of bith, {or list of mandatory cetfed documents to be submited as eppicble} [AUTHORIZED SIGNATUREE 1 horeby declare that what is stated above is true to the best of my/our information and belie DALGAON TOWN Pace Glo o 1 lz Ble |< al< Sukor Qi Signature / Left Thumb Impression of Applicant (inside the box)OFFICE OF THE KALLYAN GAON PANCHAYAT |] This Licence is hereby granted } 5/0..Abdicd...Kadana.. P.0- Kopati/Dalgaon, P.S.- Dalgaon. Dist- Darang (Assam). For carrying Trades named below for the year wai? 2 This Licence will expire on 30 june 2022. Aniyaoa.. Rike...Bexanice.... Comber. KeecBititep th be. Seon MA CA been tk fn tide, Chadha |