Sir, We horeby request that a permanent Account number be alloted to mess We give below necessary partcuars 4 Ful Name (Full Prease selec tte [¥/] as appicabie Last Name / Sumame ‘are not permitted) 2 nro atligiay aera — f Jue fale Peace ete! [y es sopcatio Last Name / Surname Frat Nar Mice Name 4 Gender (for Inividual applicants only) Cmte 5 Date of iviecorpordtnRgresmenriersipor Tran Deed Formaton of Botyof indies or eaociaion of Persons 6. Data of Pernt apa ony or die applicants), \Whother mothers siglo parent and you wish ib apply for PAN by fumshing the name of ge (ort) your ter Yee] HE] not ea) by eran tn ret matey) 1 1 1 Liltreender pine ck a appicabie) 1] [ol1) [1[9/ele LastName /Suamme A(GIN|I HO T RII Furst Name, vii s)HON U ice Nome (DIAIT Tt) Mice Name okie ‘Select the name of ether father or masher wich you ray We 1 be PAN by furmishing name of the mother oniy) [xf] raters name [_]Momer’s Name rnc yin 7 Address Residence Address Fiat | Room /Door/ Block No. Name of Premises Building! Vilage Road Sveet/Lana/Post Ofice ‘rea / Locality / Task Sub- Dison Town City / Distt Name of Premiaes / Bung! Vilage Road | Steet | Lane/Post Officeeon cat Taka Sub- Dison = Tony et [ es 8 Address tor Communication 9 Telephone Number & Email 10 details County code __Area/STD Code Pht) CLEEET maii0 ficha09081991@gmail.com 10 Status of applicant Pace tec an, {lr Finn [everest — Jpn mened onty poco: > [JPormeni im Pe Joerscntenerreane ests” Jontpetinawtics — [Jcenastorty [Jt rica pono [Junta LstiyPatreritp 11 Registration Number (or company, fms, LLPs ete) [ I ae TTT) ‘121n Case ofa person, who ia required to quote Aadhaar number/The Enrolment iD of Aadhasr application form as pe section 130AA Prease menton your ADHAAR ruber it atotes) (4[8] 3] 5] [2]2] 46] [2] 7] 7] 3: I AADHAAR number not lod, lease mention the enomet ID of Asher apleaton frm L ieee y [Name as per ADHAAR letlericard oF a8 por the Enrciment 1D of Aadhaar aplication frm R| iv Poetry Lote Ue! 13 Source of Income Please select. |v | as applicable: D sary icone temtooe prpery ——_[t] Ho ncaa LD cot care (1 me vctenentalinias aa FLT. rele ret") urs ln ae ace ‘a tapnneentra hoeemen Paes seperate estilo Giles as Ac cals siete spon. wie rte ne” Seorgaes en aoe Fel ame (ul expanded name: ale are not perma) Pease slect ite [7]es eopteatio []som []smu [ramen [Jus Last Name / Sumame | | de Name cia Ft Room oor are of Promina fond rest Lanatos ce ea LocatyTia 6b Di Tow ty Diet t tt / Uo Teron, EL 15 Documents submited as Poot of Identity (POV, Proof of Address (POA) and Proof of Date of Birth (008) tre nave encoses [ AADHAAR Card 158060 BY as proot or wontty, AADHAAR Card issued by UIDAT |] os roto astess ant [AADHAAR Gard issued by UIDAI | ys yor fst tn [Please reer t he tucons (as specie in Rule 114 of 1 Ries, 1962) or tof mandatory certed documents 19 be submited appcabie (Arner A Amerure 8 & Annes Ca tobe used whetever applicable] 16 we URMILA DWIVEDI tne appicant, in the capacty ot [HIMISELFIHERSELF # do hereby declare that what is stated above s true to the best of my/our information and betel Place Datea Government of india fer afer Jnmila Dwived! art Far / DOB ; 01/01/1098 afta / FemaleIN ya Address WO: ier aT, 345, aier, war WIO: Durgesh Kumar, 345, ee, GEE, Ba, ea wae, khadoha, Chak Khadeha, 471825 Khadena, Chiatarpur, Madhya Pradesh, 471525, 4835 2246 1773