|Application Source: I [Paymont Reference: Payment Date: ll [Application Number{AO (0207/2024 Rs.107.00/- User tt 463645340013. UserNeme| iY | ‘Assessing officer (AO code) [PAN CARD MODE Both physical PAN and e-PAN Card [pplication Mode : Physical Application’ ‘area code Owe Form No. 408, = Application for Allotment of Permanent Account Number [in the case of indian Citizens! Indian Companies! Entities Incorporated in India Unincorporated entities formed in indi "Wome pone ne sooner nemacam Sg aro go oe Range code | AONe. BlPl[e Ww Lie ge below necessary parteuars 3 3 9 2 Sts mitten ln ee oe 1 Full Namo (Full expanded namo to be mentioned as, pearing in proof of identityladdross documents ints are not pormites) Pease neti [/Josapstate [v]sm [fom [ |eumon [be Lastane tirana BARU | LL Fete B/HALG|WAN Mt None SUNIG|H 2 ABreatons of the sbove name st you mould the ob pte on te Pa BIH/A/GWIAIN|] (S|I|N|G/H| |S A/H|U| | Iyer, pase gve tater name 3 Have you ever been known by any other name? (Y] No (please tick a applica Please select tite, | 7 ]as apptcatle jst LastName Sure a First Nome l Mile Name 4 Gender (for individual applicants only) Details of Parents (applicable only for indivi ‘Whither metnei 2 single parent and you wish Iryes please lh mother's namin the appropiate 5. Date of Biaivincorporation/AgreementPartnership or Trust Deed! Formation of Body of individuals or association of Persons. 7} wale J ramate Sl) oer nie nope) oor PA by hinge name formate oy Ye — pa ponte ow, ingle parent and PAN s epplld by furnishing the name of mether erly) {Last Name / Sumame [sJayH[uy | First Name lH[Rial | Midd (CTATE [ Mothers's Name (optional except whers mother isa single parent and PAN furnishing the name of mother only) Last Namo / Sua Fst Name Mile Name PAN by furnishing name ofthe mother only) 7 Address Fiat Room / Deo Bock No, Selec the name of ether father or mother which you my keto Ba pled on PAN car iar ooh) (trcase no opten 's provide then PAN cor willbe issued wth fathers name except where mone single parent and you wish o poly for 7] Fatner's nome [T] Mothers Name (net apts Residence Address [ f Nam of Prmisas Buldng/VElage AL LP U RIA ‘ea Locly Takka Sub- Dison SInA | i v Road / Soot Lana!PostOfio 7 B 8 ‘Town Cy Dict zimJclz/= ‘3 />[a/0| ALL ‘State / Union Tetory Pincode /Zip code County Name H 14 [6211 [0] TNDIA Ottice Adaress: Name of ofce C12} jolalal=fe MADHYA PRAD [ [ Flat Room / Door Block No. "Name of Premises /Bukding / Vilage oad / Steet /Lane/Post Offspe Loan Tana eur Owen LL TIT tt1tttl Town iy ict coor EEE} 8 das to Communication 7] Residence [Llorrco eae ik as aptebi) 2 Tele None Ena eat County cote NealSTD Code ‘lepton ob uber 3[2 elel7[2[«[[e [9/7 maiio[ganopushkar245¢@gmai.com 10 Status of appcant Pees eset sane, [7] apteie — 7) ictus Hind undivided tomy [_]company Pacinersio Fe LD accociaton of Persens russ Jooayorinciuae ce Ashoty Jat! rdclPenene [—]umted Laity Pare 1. Raistraion Number or company rms LPs et} tatnGews ef pron wh To ogee gol adn net EoimertD ot chee’ appeal Tom par section 138AA Pose norton our MOHAAR mumoe(ftetes) (61 3] 80] (9[1]7]0] [213] 81 8 \TAADHAAR numbers no ated, pose mento evoten 10 Aaa aptcaton fm [Name as per AADHAAR letter/card o° as per the Enrolment ID of Aadhaar application form - B/HJA|G|WIA|N] [S/t[N]G[H] |S]A/H] UI 1 1 dE avons ewe wie [7] or applet Li suwy Ll teonstemttumpoeny [2] natn LL conta cane remem biine/oremaien martasscin [_[_] poecotanatrhinasiny [] necnasenonersaaae {7 Reprecentatve Asessee (A) ren a cis na ir SA TCA a a oe STO teonglen me oaurn 18 Full ame (ul expanded name: tls ar not permite) Praseseeative[7]asapeteaie [Jam [Jn [rumen TJs ‘LastName Fest Name / Sumame Nido Name Address Flat Room / Door Block No, Name of Premises / Busing / Vilage Road / Stoot/ Lana Post Offeo ‘Ara | Locality / Taluka’ Sb Division ‘Towa / iy Distt ‘State / Union Terntoy 15 Documents submitted as Proof of entity (PO), Proof ef Address (POA) and Proof of Oate of Birth (0B) ie nave enciosed as proot of [_AADRAAR Cardissued by _ | Pncoe ‘2 poof of dantty, AADHAAR Card Issued by UIDAT | ‘eddcoss and [AADHAAR Cara issued by UIDAT 2 poo! of dat of bith [Please refer othe instructions (as speciied in Rule 114 of IT; Rules, 1962) for lst of marcato certified documents to be submited 3s appcable) [Annoxur@ A Amorure 8 & Annoxure C ae obo used wherever applicable] 16 we BHAGWAN'SINGH'SARU |. the appicant, in the capacay of [INSELF/HERSELF do hereby deciave that whats stated above ise to he best of myfour information and boi Prace : GUNGA y 4 ‘Slgnatze Let Thumb impression of Applicant (aside the box)EIrcomesrcors Government of India SCCM Oa ICM IGE tl Unique Identification Authority of India -amiart 596” Enrolment No. 0518/18058/00017 “en Riee {Bagwan Sngh Sabu ‘90: Hra Lal Soh ‘ini, TC: niga, PO: Kutaipura, Sub Distr seasia, Diss: hop, ‘State: Madhya Pradesh IN cade: 62104, Mobi: 8267245007 fae arraaer airerg arate / Your Aadhaar No. 6380 9170 1358 VID : 9170 944 6469 8692 AR aren, A GeEaet AR. 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