Application Number: A076108603

Application Number Bar Code 3196140028817652 / PY0105286678

Payment Reference: Inward Number Bar Code
Payment Date: 15/07/2023 Rs.106.90/-
Application Source: EWALLET - A - CSC E GOVERNANCE SERVICES INDIA LIMITED Application Date: 15/07/2023
User Id: 267322740010 User Name:

PAN CARD MODE : Both physical PAN and e-PAN Card Application Mode : Digital Application

S H L W 2 9 3

eKYC-Application

✔
I S L A M
S A I F U L

S A I F U L I S L A M

3 1 0 8 1 9 9 7

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)
H U S S A I N
I S M A I L

Mothers’s Name (optional except where mother is a single parent and PAN is applied by furnishing the name of mother only)

(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) ✔

C / O : I S M A I L H U S S A I N
M O R I O M N A G A R B A L A D M A R I
C H A R P T - I

G O A L P A R A

A S S A M 7 8 3 1 2 1 I N D I A
 ✔

9 1 9 1 8 8 7 6 6 4 1 6 4 2
easminamomin@gmail.com

8 2 5 5 5 1 0 6 8 7 9 3

S A I F U L I S L A M

AADHAAR Card issued by AADHAAR Card issued by UIDAI

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

SAIFUL ISLAM HIMSELF/HERSELF

GOALPARA
eKYC-Application

1 5 0 7 2 0 2 3
 Enrolment No.: XXXX/XXXXX/XXXXX
To
Download Date:15/07/2023

Saiful Islam
C/O: Ismail Hussain
Moriom Nagar
Baladmari Char Pt-I
Goalpara Assam-783121
Issue Date:27/08/2021

Signature Not Verified

Digitally signed by DS
UNIQUE IDENTIFICATION
AUTHORITY OF INDIA 04
Date: 2023.07.15 14:04:31
IST

8255 5106 8793

Saiful Islam Address:

Download Date:15/07/2023

C/O: Ismail Hussain, Moriom Nagar,

Date of Birth/DOB: 31/08/1997
Issue Date:27/08/2021

Baladmari Char Pt-I, Goalpara,

Male/ MALE Assam, 783121

8255 5106 8793 8255 5106 8793

 Consent Form Aadhaar holders

Biometric and/or OTP based eKYC and Aadhaar Authentication

PAN/ApplicationNo.:
A076108603

Name as per PAN card:760255072247

SAIFUL ISLAM

Aadhaar number: xxxx-xxxx-8793

Name as per Aadhaarcard: SAIFUL ISLAM

Declaration:

I do hereby confirm that the Aadhaar given above has been issued to me by UIDAI. As a
part of process, the Aadhaar/eKYC data may be used only for the requirement of PAN
allotment.

I state that I do not have any objection in authenticating myself with Aadhaar based
authentication system and I hereby provide my consent to use my Aadhaar number,
Biometric and/or One Time Password (OTP) data for authentication for the purpose of
fulfilling the requirement under PAN process.

I understand that the Biometric and/or OTP provided for Aadhaar authentication /
eKYC data shall be used only for authenticating my identity through the Aadhaar
Authentication system for the purpose of only PAN allotment process.

This is further acknowledged that while submitting through Change Request Form in
PAN data. If in case, Aadhaar is not linked with PAN then through this process
Aadhaar will not be linked with PAN i.e. will be used for authentication /eKYC
purpose only.

I understand that complete security and confidentiality shall be ensured for my personal
identity data provided for the purpose of Aadhaar based authentication.

Date 15/07/2023 Signature / Thumb Impression

Signature Not
Verified
Signed by :SAIFUL ISLAM
Date : 15/07/2023 14:10:47
Reason : eSign Service
Location : India