|Application Nt TUN [ane cross SESAGLASS Ipaymontdate: {06/11/2023 Rs.107.00/- a | Application Source: [EWALLET - A - CSC E GOVERNANCE SERVICES INDIA LIMITED |Application Date:[06/11/2023 [User id:[214465330015 Juser Name:{_ eae sical PAN and e-PAN Card lication Mode : Physical ES a {in the case of indian Citizens Indian Companies! Entities incorporated in India! Unincorporated entitios formed in india] ‘See Ruse 114 ‘Assessing officer (AO code) o Wal AO vpe Range code AO No. | - k[ nw 2|6 Ce ee ay ome : : aaoaeee | 4 | Ase te a ie es aus mille peace nest ree eee | He 318 oh oe ii 1 uit Name Ful expanded name to be mentioned as appearing in proot of meee docaens Tae are not permitted) Piease select tte, [y/] as applicable sna sem umari [fans Last Namo / Surname (A ADDU IIL FestName M/O/H/A/M/M/A/D Ah vations of the you te MO}H A[M[M[A Alaloit|t a a 3 Have you ever been known by any other name? tpn toe pe tetera Preave ect ite [7]e apotcave []sm Lat Name ura Frat Name Middle Name 4 Gender (for individual applicants oniy) 5 Date of Bithvincorporation/AgreementiPartnership oF Tr r Formation of Body of individuals or association of Persons 1{2] [ol (ora) [2 {6 Detals of Parents (applicable ony for individual applicants), \Wnether mother a single parent and you wish to apply fr PAN by fumishing the name of your mother only? Yes| ityes please filn mother's name in te aperoprat space provided below Fate’ ame Mann excep were mar ingle and PAN apa yamitng ena mero Last Name / Sumame i FistName isle Name I Mothers's Name (optional except wher ingle paren and PAN appleby urshing te name of moter en Last Name / Sumame Fist Name | Midote Name Se Stace name of ite ahr of mother ih you may Te be pind on PRN ar ron o (inease ro opten is proved ren PAN car be sued wi far s name except where mate's a snl parent and you wish to apply for Paioytnsingrane ce mote'o0) [/]ratrsnem []hotersane maw aqae 1 mate Ate aoe po Fuinomiomowave Nemec romss/oucea’ ve (MIOLHTATEIFIAT-TAINISIA Road / Street / Lane/Post Office M/U/H|A'M M/A D/A/B/A/D ‘tea /Locaity Taka’ S- Dison (M]U|H|A|M|M/A/D/A[B/ AD Tou | City Distt MIAlU EL ‘State / Union Tero ____Pincode Zip code (UTTAR DESH |2|7[6|4/0|3 Office Address Name of fice Flat! Room / Door / Block No. Name o Premises Buking/Vitege Road / Steet /Lane/Post Office‘Area / Locality Takka Sub- Division Town / Cty / Distt UTTA 8 Address for Communication 9 Telephone Number & Email 1D detaits County die NeefSTD Coca : fell CLL TO ‘Email 1D [email protected] 10 Sus o ppicant Vio Soetans, [7 Jos opeene [clones PZlewo Efren tty -[Jnpany [olpornesty Fem [Clpceciton of Peeve jue Jotyatietuas cca tcl Snead! [htt tan Penn ‘11 Registration Number (for company, firms, LLPs etc.) Te 12 In Case of a person, who Is required to quote Aadhaar number/The Enrolment IO pease merten you MADHAAR er (ates) [8]4 11] 2] [7] 6 als HAADHAAR number is not alloted, please mention the enrolment ID of Aadhaar application form [Name 2s per AADHAAR leitericard or as per the Enrolment MO] H|A[M]M) TT T sé scien Day LE ta Hase psc IE] tse pooner mutuals’ {Representative Aaseones (PA) i naiacesian ie fie ona. nent Soong weweaun OF Parnes an apanass nee ss on porno ¥ |28 applicable w Prease select tite, Last Name / Sumame Fst Name idee Name Address Fat / Room / Door / Block No. Name of Promises / Bing / Vilage Road / Steet / Lane/Post Office ‘cea / Locality /Talukal Sub- Division Town City /Distnet State! Union Teitory P UTTAR 415 Documents submitted as Proof of kdentity (POI), Proof of Address lie have enclosed | _ AADHAAR Card issued by | as pro ot entity, (POA) and Proof of Date of Birth (008) |AADHAAR Card issued by UIDAT | as prot of aaaress ana [AADHAAR Card issued by UIDAT |) as prot of date of bith [Proase reler tothe istuctons (as speciied in Rule 114 of LT. Rules, 1962) [Annexure A, Annexure B & Annexure C ae to be used wherever appicatle] 18 wie| MOHAMMAD KADIE te appican. in to cpocty of [HIMSELFHERSELF for list of mandatory cortiied documents to be submited 3s applicable] {do hereby dectare that what is statod above i rue tothe best of myiour information and bebt. Pace Date