Form No.

49A
Applicalion forAllotment of PemanentAccount Number
I n the case of lndian citizens/lndian Companies/Entities incorpo.ated in lnd a/
Unincorporated entities formed in lndial
S€.Ruleli,l

Assessins officer (Ao codo)

fai N-
tltlttltl I

slr
l/We hereby request thata permanent accolnt number be allotled lo he/us.
€s(r?d
nrye g ve belownecessary particulars: T ".b
sDd,*/ 1"1,n r@s-
l FullNahe (Fullexpahded name to be mentioned as appea.ins in proofol ldenliiy/date ofbirth/address documeats:lnilials are not pemitted)
Shri Smi.

Last Name / Surrame t x' i+ I

.A
P L, ( P l: N a K
I

2 Abbreviations of lhe abovs name, as you wolld like lt, to be printed on the PAN card

P U5 t-i t /: D P0 k t) t\ tr t(
i

3 Haveyou everbeen known byany othe.nahe?

EI-* (please tick as applicable)
ll yes, pleas€ q ve thatother name
p-sr,i Smt.

Lasl Name / Surname

4 Gender (lo. lndividual applicanG only)

E}-"" ! r-."s".a- (plea.e rick as applicable)
5 Date of Birth/lncorporalion/AgreemenUParlnership orTrust Dood/ Formation ol Body of individuals orAssociation ot Pe6on!

5 cl + trlof616-l
6 oetails orParenis (applicable ohly for lndividual appllcanis)
Whether mother s a single parenl and you wish to app y for PAN byiurnishinglhe name of your molher only?

No (please lick as applicable)

li yes, please fllin
mothefs name in the approprale space provids below'
Father's Name (Mardatory excepi wherc motheris a sinqle parcntand PAN i3 applied by furnishinq the name of moth* only)
( t) p F ( 11 L
,fr
r
Mothers Name (optlonal except where molher ls a slnsle parenl and PAN ls applied by fumlshlng the name of mother only)

s the name of eilher falher or motherwhlch you may like 10 be prinled on PAN card (Se/oct 016 only)
(Ptea* tck as appticabte)
(ln case no oplion is provided ih€n'PAN card will!e jssued wilh faheis name except where mother is a single parent and you wish to apply for PAN
by tum shing name oithe mother only)

Residence Address
Flal / Room / 0oor / Block No. ff - .-] rfTrfrfrTrrrT
m jTmr:
T
Name of Premlses / Bu ld ng /Village

Road i Slreel / LaneiPost Oflice ff TFFF -TT-rT-r

Trrrrn- -m]I
IT -TTrtT-fT
AEa / Lmality / Taluka/ Sub- Division
Town / Clly / Districi tl :T:F -[rfl_[
Slale / Union Territory

\\'t rA{ PiinF(tl 7 +1" L :

 Flat/ Rooh / Ooor I BLock No
Name of Premises / Buid ig / Vlliage
Road / SUeet/ Lane/P.st offce
Area / Localtv /Ta uka/ Sub_ Division

Otfice (Ptease tick as apPlicable)

I AddressrorCommrnication
I Telephone Number & Email lo details
code Area/STD Code
t4t ltA -Tt
EnralLlD

10 Status of applicant
Please select stalus,

! rnoi,iou"r Hindu undivlded lamllY tr Assoclation of Persons

f r."t" tr Artilicial Juridical Persons Limited Llab lity Padnersh

11 Regisiation Number (for

*Otraar appticalion form as Per section 139AA

number or nr tO or
12 ln cas6 ofa pereon,who is required to q uote Aadhaar
(if allotted)
Please mehtion your AADHAAR number
Ii AAO HAAR number is not allottd

Name as peiAADHP'AR

13 Source of lncome

lncorne Irorn Olher sources

IFor code: Refer inslruclionsl
lncomefromBusiness/Profession Busines'Professioncode
ln.ome from House PrcPedY
whoseparticurarshav
" ::i'":#::'i:",j:ffi:"^ff1**",r.o***",,hoisassessibreunderlherncomeraxAcrinrespec,ortheperson
becn given i. the column 1-13.
Fuu Name (FullerPanded name: initials are
not Permitted)
shi Sml

FLat / Room / Ooor / BlockNo,

Name of Premises / Buildlns / Mllage
Road / Skeel / Lane/Post oflice
Area / Locality / Taluka/ Sub_ Divlsion

(POA) and Proof ol Dale of Binh (PoB)

15 Documents submitted as Pr@f ol ldentitv (POl), Proof ofAddress

as prool oi date oJ bidh

as p.ooi ofaddress and to be submitled as applicablel
(as l.T, Rules,1962) tor list ol mandatory cedilied documents
lP ease reier lo the lnstr!ctions
Annexurc B & Annex'rrc c are to be used wherever applieblel
iAnnexureA,
lhe applicanl, in the caPacity of
of my/our inJormation ard belief
by declare that whal ls stated abde is kue io the besl
<ilr+<qf+r5
D D N1
sionaturc / Leflrhumb l Press on
Appli€nt (lnside llie box)
L
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iF iai\ / DoB : lsro7/roo5

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ijniqLre Ldenificalion Authont,v ol lfd a

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r:rar.rra a EL::r rrirerr.n, trtrar

6232 7'124 3738

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i@ RftrooE ol,or/i971

41 29
fr{T .: -, *t qdqrfl

Unique lddntificatioB Aulhority of lnd a

ffi: ."rsF RF qE,liFt

6q- m' triq( 6B 'rEa (hdi (l.reham Etah
Ahmad

6',t42 9741 3329

A' {a lwwl
 Appticant,s Copy
Tax lnvoice cum Acknowl edgement
rtcoipt of PAN Appllcauon (Forn ,r9A)
P - 910243300540221

C6tesory

Data or Bl.lw tncoDoraton

Commuhi.ation Address stare
UTTAR PRADESH (9)
Tolephono/ itobflo Numb..
EJnall lD PK97209042@cMAtL.COM

AADBAAR Cad issued by lhs Unque

Eenl tiE di
Proof of DOA

191.00
il:Hi;'lli11i"iff :ffi [ I#H:::.";ffi::"T:ii,ttr]i?l_ ccsI 9%
"*.",,,_,, 10.00
SGST9% r0.00
tGsI.tS% 116.38
Total(Rounded orq {107.00
GSItN:27AAACN2o32NtZs
CI N U 729OOMH 1 99 5PLC09 5642
SAC :998319
c) rBt 3031
@ 'r$l I
T
.F
\$)
ll fl
sMs ty 5

ii ., L:lJt l_/til6l\l
6 oelails ofparenrs (app[cable
onry fortndividua
Wherher morher is a single pare and you wish to applyiorPAN
byfurnishin! the nam6 o, your morher
onty?
No (please rick as appricabte)
iin motheis name in the a
PProPrate space provide betou
e (Martdarory excepr whe
lngl e parentand PAN is a
( ipF ( L 't K
by furnishing tho name

lVother,s Nafte (optional o(cept

where

eilher hlher or morhe; which you may tikebG

p/r"t"r" *n," on PAN card (Se/6ct one only)

(rn case no oplion is orovided

ihen'pAN cad wilt be issued wilh fathels name exceptwhere
by iuhishins name oi th6 motheris a singre parentand you wish
lo apptyforpAN

ResidenceAddress
Flat / Room / Door / Btock No.

Name of premises / Buitding / Viirage

Road / Srreet / Lane/posr Orice

Area / Localiiy/Tatuka/Sub- Diviston

Town / City / Disiricl

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