U-K002301873

PY0010395808
24/03/2024 17:43:31
D:PANM-PA7086950145 Amount
UserI : Rs.:106.90/- 24/03/2024
UserName: PANM-PA7086950145 Appl
icat
i ce:PSA
onSour - ETN - PAN MITRA
dMode:Both physical PAN and e-PAN Card
PANCar Appl
icat
ionMode: Digital Application

D W I P D 6 3 1 9 C

✘
✔
D A S
S U C H E N

S U C H E N D A S

D A S
M A L A R A M

0 1 0 1 1 9 7 2
✔ ✔
✔ ✔ ✔

C / O : M A L A R A M D A S
K H O L A G A O N M A Y O N G

M A R I G A O N

ASSAM 7 8 2 4 1 1 INDIA

9 1 6 9 0 0 9 6 1 8 8 0
arjunbordoloi2017@gmail.com
✔ 4 5 9 1 2 3 2 0 5 2 5 3
S U C H E N D A S

DW I P D 6 3 1 9 C
SUCHEN DAS HIMSELF/HERSELF

3
TIKHABORI

2 4 0 3 2 0 2 4
 Enrolment No.: XXXX/XXXXX/XXXXX
Download Date:24/03/2024

To
Suchen Das
C/O: Malaram Das
VTC: Kholagaon
PO: Khulagaon
District: Marigaon
State: Assam
PIN Code: 782411
Issue Date:12/01/2021

Signature Not Verified

Digitally signed by DS
UNIQUE IDENTIFICATION
AUTHORITY OF INDIA 04
Date: 2024.03.24 17:45:34
IST

4591 2320 5253

Download Date:24/03/2024

Suchen Das Address:

Issue Date:12/01/2021

Date of Birth/DOB: 01-01-1972 C/O: Malaram Das, Kholagaon, PO:

Khulagaon, Dist: Marigaon,
Male/ MALE Assam, 782411

4591 2320 5253 4591 2320 5253

 Consent Form Aadhaar holders

Biometric and/or OTP based eKYC and Aadhaar Authentication

PAN/ApplicationNo.:
K002301873

Name as per PAN card:760255072247

SUCHEN DAS

Aadhaar number: xxxx-xxxx-5253

Name as per Aadhaarcard: SUCHEN DAS

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 24/03/2024 Signature / Thumb Impression

Signature Not
Verified
Signed by :SUCHEN DAS
Date : 24/03/2024 17:54:00
Reason : eSign Service
Location : India