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A.OA-546-794
1 523632001 6
AN CARD MODE : Both physical PAN and e-PAN Card
Forrn No.49A
Applicalion for Allotment of Permanent Account Number
in lndial
[tn the case of lndian citizens/ lndian companies/ Entities incorporated
Unincorporated entities formed in lndial
See Rultr 114
To alotd o}stakus, l)lea5e t{rllow lis acocnlp{lyin$ itsl.uctions i?oa uxanli)ies l}efo1a lrllr:8 UF lho loau
Assessing officet (AO code)
AO type Range code AO No.
c H E W 1 4 1 9 2
sir, lffie hereby request lhat a permanent Account lrumber be allotted to rne/us.
lArye give below necessary parliculars:
1 Full Name (Futl oxpanded namo to be msntioned as documents: initials aio not Permittod)
Please select tlile, applicable Shr
ffias
Last Name I Surname
First Name
Midclle Name
S E L I E L U
3 Have you ever been known by any oiher narne? E*o (please tick as apPlicable)
lf yes, please give thal ather n8me
Please select title, [y'J as apptrcable
Last Name / Surname
First Name
Middle Name
4 Gendor (for lndividual applicants only) [l r.ln"tu !ron"e.no". (please tlck as applicablet
Ysar
Doed/
5 Date of Blrth/hcorporation/AgreemenUPartnership or Trust
Formatlon of Body of individuals or assoclatlon of Persons t1 J, j 8161
i;'-?1 I
1....Y -.- | I
6 Details of Parente (applicable only for lndividual applicants)' r-'r .. l-t . ,
as
Whether mother is a single parent and you wish to apply for PAN by fumishing the name of your mother only? Yes Ll No lgl (please ucK
lf yes, please fill in mother's name in the appropriate space provided below.
Fathers's Name (Mandatory except where molhgl !9^a :ing-le parent.and.PAf'l ls the name of mother
furnishing the name mother only)
Mothers's Name (optional except where mother is a
Last Narne / Surnanre
Select the name of eilher father or molher you may like to be printed on PAN card (wte,"r. oilt orttr)
for
(ln case no option is provided then pAN card will be issued with father's name except where mother is a single parent and you wish to apply
PAN by furnishing name of the mother onfV) Father's name [l Uother'o Na." (t't(at{ ti<:kar.tt*ti,ohtu)
Address
[
Residence Address 1
Flat / Roorn / Door / Block No
K A M A P U R A M
Name of Premises I Building / Villaqe
Road / Stre et I Lane/Post Otfice
N A A GA R o lrL S R E E T
R K P E T T A T L U K A
Area i Locatity i Talukal'Sutr Division
Town/CityiDistrict T R U V A I IJ R I
State / Union Territory Pincode / Zip code Country Name
TAMIL NADU 6 3 1 3 0 3 INDIA
Office Address
Name of office
Flat i Room i Door / Block No.
Name of Premises I Building i Village
i Street /
Area / Locality / Taluka/ Sub. Division
TownlCity/Distriet
I
8 Address for Communication
Telephone Number & Email lD dotail,
Residencs
tr Office (Please tick as applicablo)
Country code AreaiSTD Code Telephone / Mobile numbsr
iqlil
t,l-tlltllllI I i-1""T- I I
Email lD
10 Status of applicant
Please select status,
lf ,- as anrtrcaote
[-l H,nou unclivided fami y
!.oro.n, nPartnership Firm Assoctarion of persons
f]
Body of lndivaduals locaiRuthor[V persons
! nart,fi.,"t Juridicat
l-l t-tn,ir* Liabitity partnership
11 Reglstration Numhor (for company, flrrns, LLps etc.)
1 2 ln Case of a person, who is required to quote Aadhaar €r sectlon 1 3gAA
Please mentron youTAADHAAR number (if allotted)
lJ r^ rF
lf AADHMR
^ ^^' number is not allotted, please mention the enrolmenl lO olAadhaar
application form
Nam s as pe r MDHAA R I e rte rrcard ;;;d ih. i;lm;"8;hh;lr;;h;,Ha
13 Source of lncome
n Salary
! ,n.onl" from House property
Eto rncome
as applicable
tr
l_l lncome from Business / profession
14 Representetive Assaaaee
Business/Profession code
t-Li [For Code, Refer instructionsJ ther sources
{frA)
Full name' address of the Represenlative Assessee. who is
assessible under the lncome Tax Act in respect of the person,
been given in the column 1-13, whose particulars have
Full Name (Full expanded name : initiale are not permitted)
Please setect rith, as appticabte
[7]
Last Name / Surname
Firsi Namo
Middle Name
Address
Flat / Room I Ooor tBtock No
Name of Premises / Builcting / Village
Road / Stre€t / Lane/Post Office
Area / Locality / Taluka/ Sub- Division
Town/City/Distncl
State / Union Tenltory
Pincode
15 Documents submitted as proof f ldent
l/We have enclosed SSU
as proof of identity, ISSU
[Please rofer to the instructions (as specified in Rule 114 of l.T. Rtrtes, '1962) for list of mEndatory
certifaod documents to b€ submitted as applicablel
[Annexure A, Annexure B & Annexure C are to ba ueed wherever applicahlel
16 t/we;sEwrvflU-- , the applicant, in the capacity of
do hereby declare lhat what is slaled above is true to ilre
best of my/our in{ormation and bBlief.
Place :
'ARKUPPAM TIRUTTANI
Signature / Left Thumb lmpression of Applicant (inside the box)
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Governmenl ol lndi9
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u6lq ercor-u.tnen6 / Enrollment No.: 0654/1 129914569g
To
Oeeberll Geligt . INFORMATION
Selvi Velu I Aadhaar is proof of identity, not of citizenship.
_ WO: Velu
5 VINAYAGAR KOIL STREET KANDHAPURAM
I To establish identity; authenticate online'
$ n x eerral
f Valakanampudi
- Ramakrishnarajupeta
Pallipattu Tiruvallur
- Tamil Nadu 631303
2 7448481547
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p-rfus6iT e5ptr[ 6r6uur / your Aadhaar No. r Aadhaar is valid throughout the country.
:
5497 0037 7,151 r Aadhaar will be helpful in availing Government
and Non-Government services in future.
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Oosberll Geugt
Selvi Velu
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OD6g Dn5h / DoB : 30/06/1986
Quaiuunei-r / Female
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Address: W/O: Velu, VINAYAGAR KOIL
STREET, KANDHAPURAM, R K PETTAI,
Valakanampudi, Ramakrishnaraiupeta,
Tiruvallur, Tamil Nadu, 631303
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