‘Acknowledgemer Neomeor x sevasezvoroes HAAN I Request For New PAN Card Or! And Changes Or Correction in Permanent Account Numbsr (PAN) AMPPAOSE2S Please road Instuctions t’& ' fr selacting boxes on left margin ofthis form seroveime pa [5 1.Full Name (Full expanded name to be mentioned as appearing In proof of Identityladdress Please selecttiti, as applicable =X shi C) sme 1 Kumari ) Ms ‘Spas LeA Thane essen or ‘Agpicart (side the box) LastName surname First Name ‘MOHD Midcle Name "ASHRAF Name you would like it printed on the PAN card [MOHD ASHRAF LONE ] [1 2etalls of Parents (Applicable only for individual Applicants) ‘Whether mother is a single parent and you wish to apply for PAN by furnishing the name of your mother only? Yes OC) Nol Iyes,please fllin mother’s name in the appropriate space provided below. {please tick as applicable) Father's Name (Mandatory except where mother is a single parent and PAN is applied by furnishing the name of mother only) Last Name!Surmame LONE FirstName ‘MOHD Midcle Name ‘SULTAN Mother's Name (Optional except where mother Is single parent and PAN Ts applied by furnishing the name of mother only) Last Name/Surname First Name Middle Name Select the name of edhe Father or Mother whieh you may ike To be printed on PAN Gara (Seed! ane any) In case no option is provided then PAN Card will be issued with Father's Name. Father's Name_ Mother's Name o {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 mother only) IZ) 3. Date of Birtvincorporation/AgreementPartneship or Trust Deed! Formation of Body of individuals or association of Persons Day Month Year 09/05/1986 oO 4. Gender(for individual applicants only) El tale 1D Femate 5. Photo Mismatch DB esignature mismatch 7. Address for Communication TE _ Residence OD ottice ven ot > Fat Roem Dee oc No, Nome of Premises Sula Vig ee a ‘Transgender Town / Gy /Distnet Banalpore: Slate Union Teratony BIN Gone ZIP Goa nice Nate (Leann AND 193502 om INDIA, IMyou desire to update your other address also, give required detalls In additional sheet, 8. Telephone Number & Emsil ID details ‘Telephone | Mobile number Country code AreaiSTO Code a 9596751096 Email 1D LONEAASIFZS@GMAILCOM |EfI10. Please mention your AADHAAR number (allotted) Rrra T [Name as pe AADHAAR etercard ] MOHD ASHRAF LONE IN. Mention ther Permanent Account Numbers (PANS) inadvertently alloted fo you PAN PAN PAN PAN 42. Verification eo do hereby declare that what ls tated above Is tue fo the Gest of myo information and belief belt. lowe nave enclosed enangesicerrecions [4] (number of documents) in support of proposed Place ‘BANDIPORA phi vv bate SpaaaaT LST TRIN TEES48, Other Address : Name of omee Flat / Room / Door / Block No Name of Premises / Bung! Vilage Road Street /Lane/Post Office ‘Acca / Locality | Taluka’ Sub- Division Town / Cty | District, State / Union Tertony PIN Coxe ZIP Code Country Neme ‘Signature /Left Thumb Impression of ‘Applicant (inside the box)