ny rss at Permanent Account Number (PAN) Request For New PAN Card Or/ And Changes Or Correction in PAN Data eee Please read Instrucions 1 & 1 Tor selecting boxes on lett margin af ths form. L] Tul Name (Ful expanded name to be mentioned as appearing in proof of identityladaress documents: initials are not permitted) Please select tie, [Z]as applicable []shi [—]5m [T] Kumari []ms Last Name / Surname Fist Name Middle Name ‘Name you would like it printed on the PAN card [ | l J [CJ 2 ata of Parents (applicable ony for Individual applicants) Father's Name (Mandatory Even married women should fil in father's name only) Last Name / Surname | First Name | Middle Name } Mother's Name (optional Last Name /Surame | First Name | Miaae Name ] Select the name of elthe father or mother which you may Ike fo be printed on PAN card (Select one ony) (ieaee no opin i provided then PAN card wll be esd wt father name) Father's Name Mother's Name (Please tick as applicable) [2 bate of irthtncorporaion/AgreementPartnershiprTrust Deed! Formation of Body of indviduals or Association of Persons 4 4 Gender fr indivduat appeant only) (ma (Clremate (Please tick as applicable) 5 Photo Mismatch 6 Signature Mismatch 7 Address for Communication Name of Office te th snyn ct tain arn FlatRoom’ Door / Block No, Name of Promises! Bulding/Vilage [residence [Jomee (Please tick as applicable) RoadiStrest! LanelPost Office ‘Area I Locality Taluka ! Sub- Division ‘Town City / District ‘State Union Tero Pincode7 Zip code Courity Name [8 yeu desire to update your other address also, give required details In addtional shi [9 Telephone Number & Email ID details Area/STD Code Country code Telephone / Mobile number EmailiD [110 AADHAAR number (Talo) Name as per AADHAAR lettericard [ { { [118 Mention other Permanent Account Number PANS) inadvertently allotted to you pant(T TT TTT TTT jean2l TTT TTT TTT jeans] [TT TTT TTT leanslT TT TTT TTT} 12 Verifaion Ie re apptican, inthe capacity of (ae rreraby declare that what fs stated above Ie true fo the best of mylour information and belie. Wo have enclosed _] number of documents) in support of proposed changes / corrections. Place DOMMYyYyy Date ‘Signals [Cal Tham Wrpression of ‘Applicant (inside tha box).