Application Number: A036893176

Application Number Bar Code Payment Reference: 1045175925164794 / PY0045882352 Inward Number Bar Code
Payment Date: 14/02/2021 Rs.107.00/-
Application Source: EWALLET - A - APNA-CSC Application Date: 14/02/2021
User Id: 735342320016 User Name: CSC CENTER PURANO JHALDA
PAN CARD MODE : Both physical PAN and e-PAN Card Application Mode : Physical Application

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Whether mother is a single parent and you wish to apply for PAN by furnishing the name of your mother only? Yes No ✘ (please tick as applicable)
If yes, please fill in mother’s name in the appropriate space provided below.
Fathers’s Name (Mandatory except where mother is a single parent and PAN is applied by furnishing the name of mother only)
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Mothers’s Name (optional except where mother is a single parent and PAN is applied by furnishing the name of mother only)
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(In 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 for
PAN by furnishing name of the mother only) ✘

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technicaljhalda723202@gmail.com

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AADHAAR Card issued by AADHAAR Card issued by UIDAI

UIDAI (In Copy) (In Copy)
AADHAAR Card issued by UIDAI
(In Copy)

SHRIMANTA KUIRY HIMSELF/HERSELF

JHALDA

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