Request For New PAN Card Orl And Changes Or Correction in PAN Data

Perrnanent Account Number (PAN)

A D r? D I 0 IB
Please read Instructions'h'&'i'for selecting boxes on left margin of this form
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Name in proof of identity/address

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Please select title, as appticabb | 1 Shri Smt Kumari M/s

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Last Name I Surname h N E R J e
First Nanre v a T g N A
Ir4iddie Name

T v 0 T S N A g A N E R :T E e

2 Details of Parents
Fatlrer's Name ( Even married women slrould fill in father's name
Last Nanie / Surname D E v
First Name J A T :t N o R A
It4iddle Nanre N A T l+
Mother's Name (,

Last Nanre / Surname

First Name l

Middle Name
Select the name of either father or mother which you may like to be printed on PAN card (select one only)
(ln case no option is provided then PAN ca!.d will be issued with iather,s name) Name Mother's Name (Please tick as applicable)

Month Year
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r [ffisioence f-iorui"" fPlease ti'ck as applicibte)

Na me Of Office 1to be f I ed onty in case oi oifice address )
lto a R. E I H L l+ * N D r. A b A N E RT E E
FlattRoom/ Door / Block No. B A B v RB A h
Name of Premises/ BuildingA/iilage B A R BA D t\4 A N
Road/Street/ Laner Post Office Bv R D w A r,l RA 5 b A TT
Area I Locality i Taluka / Sub- Division B R D t, 4 N
TownlCity/District P t, R b A B A RD ll A h A nl
State / Union Pincode i code Name
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ln additional sheet.

Cou code Area/STD Code Tele I ]Vlobile number

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Name as rlcard
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B A N ER E a E

fltPAN 1 PAN 2
allotted to
PAN
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l/We , the applicant, in the capacity of cio
declare that what is stated above is true to the best of my/our information and belief.
l/We have enclosed JZ-knurnb"r of docunrents) in support of proposed changes I corrections
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JATINDFA NATH DEY 66ri6tll - 700 069.
Ir cssc this card is lost/fbuld,ldtr.ily iriornvrctilrn to
c"ar ffttr IDATE oF BIRTI t}e i$suing authority :

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09-07-1 955 Arslstalt Conrmissioner o, Incottre-tar,
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EOMMTSS}ONER OF INCOME.TAX, W,B, . II Ctlcrtta- 7u0 069.

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Enrolment No. ' 0653/49103/01369
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ry Aadhaqr is a proof of idenlrty, not of citizensnip
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{ Jvotsna Bane{jes
orVerify idenlity using S€cure QFt Code/ Offline XMLI Ontine
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o C.O: Biresh ChaftJra Barleqee Authentication.
O BABURBAG ry This is electronically generated letter.
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Burdwan Balbari
o Barddharnan Wesl Benqal , 7j31t)4
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m Aadhaar is valid throughout the country.

x Aadhaar helps you avaii various Government
and non-Government services easily.
x Keep your mobile number & emaii lD uptlared
in rtadhaa,
3Tc-fir SiisJI": ffiJTiq / ygur .&i*dh*rar No.
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,Carry Aadhaar in your gmafi phone * use
521 5 7343 3097 rnAaciltnar App.
VID : 9171 20?1 BO0Z ZSt3

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Address:
o GO: Biresh Chandra Bane4ee, BABTJRBAG,
o Jyotsna Eanertree Barddhaman (nr;, Barddharnan.
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Dale of Bi(hlDOBr 0g/0l1r955 d West Benral - 713104
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