‘errors mos w-cevonrasessars I ANTAL NU ANT Request For New PAN Card Or/ And Changes Or Correction in Permanent Account Number (PAN) ADMPASS95C. Please read Instructions 'h’& for selecting boxes on let margin ofthis form, © 1.Full Name (Full expancied name to be mentioned as appearing in proof of identityladdress: Please selecttitle, as applicable [| shri CJ) smt CO) Kumari D) wis Sigaare Le Tne Repression oT ‘Aoplear (nde the bo) Last Namesurame First Name "AVINASH, Midate Name BHASKAR, Name you would like It printed on the PAN card AVINASH BHASKAR AHER_ J 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? Yes O Nol Iyes,please fill 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 ‘AHER Firet Name BHASKAR Midale Name ‘MAHADEO Mother's Name (Optional except where mother Is. @ 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 Cava (Select one only) In case no option is provided than PAN Card willbe issued with Father's Name. Fathar’s Nama Mothers 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 2. Date oF BirewincorporationiAgreementPartnership or Trust Deed! Formation of Body of individuals or association of Persons Day Month Year ‘4. Gender(for individual applicants only) El male Female Transgender 5. Photo Mismatch ©) csignature Mismatch 7. Address for Communication Residence D ottce Name of office Flat/ Room / Door / Block No, Name of Premises / Busdina ! Village Road’ Street/Lane\Post Offce = [Mane ‘Area / Locality / Taka’ Sub Division) Town Cay Dist Drang State Union Teton IN Cod aD Gok nko Nae LwanaRasHTen 060% al TNO ] Ifyou desire to update your ether address also, ve required details In adaltional sheet ara Telephone / Mobile number County code ‘Axea‘STD Code a 9325907125 Email 1D ‘OMNETCAFET4@GMAIL.COM [Litt Please mention your AADHAAR number (if allotted) [RRRRRRRROED i lame os per AADHAAR itiericard | VINASH BHASKAR AFER |1i11. Mention other Permanent Account Numbers (PANs) inedvertently allotted to you PAN PAN PAN PAN 42. Verification \ [RRSTORASERRTER re aoa nt cacy do hereby declare thal what is slaied above Is re To the best of mylour information end belet boli. We have enclosed (number of documents) in support of proposed cnangesiconrectons [2 Place THANE oD___hit_Yvv¥ Date Sirature TaA Thumb pressor 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)