Application

12332007 3042 I PY00901

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Payment Reference:
Payment Date:
Application Sourge:

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PAN CARD MODE : Both I PAN and e-PAN Card

Form No. 49A
Application fo. Allotment of Permanent Account Number
/r.5') In the case of lndian Citizensl lndian Companies/ Entities incorporated in lndia/
Unihcorporated entities formed in lndial
S'' RLlo 114
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Assessing officer (AO code)

Area code AO type Range code AO No.

B 1 5 b I
i 5^1,'44- e;ul
Sir, lrwe hereby request that a Permanent Acaounl Number be allotled to me/us.
l/We give below necessary padiculars:
1 Full Name (Full expanded name to be mentioned as in proof oI address documents: initials are not pennitted)
Please select ljlle, Ly' las applicable

Last Name i Surname

First Name

Middle Name
Abbreviations of t
ls all t:n
e above
nt-I BI B -l-rl-l_,--T]*TTt*Tl
would like it, to be printed on the PAN card

3 Have yoli ever been known by any other Bame?

EI*o (please tick as applicable)
li yes. please give that other oame
P,ease select lrtle. ly' i as applicable

Last Name,'Surname

Middle Name

Gender (for lndividual applicants only)

f, r'arr. @ f u-utu Itransgender {please lick as applicabtc)
Dav
Date of Birth/lncorporation/Agreement/Pannership or Trust Deed/
Formalion of Body of individuals or association of Persons o2 fflr[rTrl
Details oI Parents (applicabl€ only tor individual applicants),
Whether mosrer is a single parent and you wish to appiy for PAN bytumishing the name ofyour mother only? YesI f,,:o lZ iolease tick as applicable
lf yes, please fillin mothet"s name in fre appropriate space provided below.
Fathe6's Name (Mandatory except virhere mother is a single parent and PAN is applied by furnishing the name of mother only)
Lasl Name ,/ Surname SK
First Name
[4iddle Name
Mothers,s Name (optionat except whererllogg]:f:T.q applied by the name mother only
T
Lasl Name / Surname
First Name
Middlo Name
Select Ihe Dame of either father or mother which you may like to be printed on PAN card k.n\i N n t.')
rL
(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 for
PAN by turnishing name of the mother only) Fatne., n"n,. Molher's Name tni^r tna e\ u!'r,tnthk,
7 Address El
Residence Address
N 0 0 2 6
Flat i Room / 0oo!'/ Block No.
Name of Premises / Buildinq,r Vlllage
Road I St.eet / Lane-lPos1 Office
Area / Lccality I Talukal Sub- Division BIE R H M P o R E
Town I Cityl D,strict MIU H I D A B A D
State / Union Terrilory Pincode I Zip code
WEST BENGAL 7i?lr.:l*G-l ;T-
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IND IA
Office Addregs
Name of otfice
 Are-a / Locality /Talukal Sob- Division
Town/City/District

8 Address for Communication Residenc€ (Please tick as applicatlie)

g Telephone Numtler & Email lD details
Coufitry code Area/STD Code Ielephone / l\4obile number
0 4 2 6 2 9 5 9 6 9 9 9 4

Email lD 1 .com
10 Stalus of applicant
Please select slalus, as apnlicable
fl Governmenl

I tnairiou"t llindu undivided family Ccmpany Partnership Firn) Association of Persons

Trusls Eody of lndividuals Local Authorlty JurldicaI PersoBS Limited Liability Partnership
I nAdincial I
'11 Reqistration Number (for company. firms, LLPS etc.)

12 ln Case of a person, who is required to quote Aadhaar number/The Enralment lD gI Aadhaar application fo.m as per section | 39AA
Prease mention you. AFDI-iAAR nr.'rbe, ,,1 , 1o1,"6, lffi{ , E ,TaJ ? s g s
IiAADHAAR number is not allotled. please rnenlion the enrolment lD ofAadhaar applicalion form

Name as per MDHAAR lener/card or as per the Enrolment lD ofAadllaar applic€lion fornr

S L I N B I B I

13 Source of lncome Please selecl, Pl as applicaute

n Saia.y I lncome f.om House property E*o inconre I cuo,,u, ouii

tr
LI lncome frorn Bosiness I Prolession
14 Representative Assessee {RA}
BusinessiProfession code m JFor Code: Refer instructionsl ! lnaome hgm Other sgurces

Full name. address of the Represefitative Assessee. who is assessible under lhe lncome Iax Act in respect of the person, whose parlrculars have
been given in ihe coiunrn 1-13.
Full Name (Fqll expanded narne : initials are not permitted)
Please select lille, as applicable
E ]
Last Name / Surname

First Name
Middle Name
Address
Flal / Roam / Door / Block No. N 0 0 2 6

Name of Premises / Bualding / Village N A R I K E I B A R I

Road / Streei / Lane/Post Office S O M A R A
Area / Locality I Talukal Sub- Division B E R H A M P o R E

Town/Ciiy/Diskict M U R S H f D A B D

Slale / Union lerri{ory WEST BENGAl, 1 A 2 1 6 3 Pincode

15 Documents submitted as Proof ol ldentity (POl). Proof of Address (POA) ahd Proot of Oate of Birth (DOB)

llwe have enclosed as proof of identily

as proof of address and ns prooi of date of hirth.

lPlease refer to the instructions (as speeifi€d in Rule 114 of l.T Rules, 1962) lor list of mandatory certified doclments lo be subrnitted as applicable]
lAnnexureA, Annexure B & Annexure C are to be used wherever applicablel

16 llwe , the applic€nt in the capac ly of

da hereby declare that what is slaled above is true 10 ihe best ol my/our inlormation arTd belief.

Place : TH
gdi,ila- 9i6i
D DfuI T,,I Y YY Y
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-i>?r-i-7 Tir/ Enrolment No.: 2tag/61l Ol 161222

Salina Bibi

MuEhidab3d west Bengat' 742163

97329f,6902

3lf,fd{Tir gl!fia }R..I'I / Your Aadhaar No. :

7921 3811 6585

VID:9157 3541365917s2
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Salina Bibi
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nEfi/ FEMALE

7921 3811 6585

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r Aadhaar is a prooi of idehtity, not of citizenship.
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4 will be helpful in availing Government

and Non Government services in fulure .

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4FEr ar - 742163

WOlamirul 5k, narkiibari, p.s-saktipur,

Nankelbari. Murshldabad.
west Bengal - 742163