AA9388156_SRN_FORM_1721463350321

Form language
Form No. DIR-3
English Hindi
Application for allotment of Director Identification Number
before appointment in an existing company or LLP
[Pursuant to section 153 of The Companies Act, 2013 & Rule
9(1) of The Companies (Appointment and Qualification of
Directors) Rules, 2014 & Rule 10 of Limited Liability
Partnership Rules, 2009]

Refer instruction kit for filing the form 1721463350321

All fields marked in * are mandatory

Income-tax Permanent Account Number (Income-tax PAN) is mandatory in case of Indian Nationals and in such case applicant
details should be as per Income-tax PAN. In case the details as per Income-tax PAN are incorrect, applicant is advised to first
correct the details in Income-tax PAN

In case of foreign national, Passport number is mandatory

Digilocker

1 Fetch from Digilocker

Applicant’s Details

2 *Photograph
(Attach a latest passport size photograph by clicking on the alongside box)

3 *Whether a citizen of India Yes No

4 Applicant’s Name (Enter full name and do not use abbreviations)

(a)First name HIMATLAL

(b) Middle name RAMJIBHAI

(c)Last name GORI

5 Father’s Name (Even married women must also give father’s name)

(a) First name RAMJI

(b) Middle name

MANGALDAS

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 (c) Last name GORI

6*Nationality India

7*Whether resident in India Yes No

8 (a) *Occupation type

Self Employed Professional Homemaker

Student Serviceman

(b) Area of occupation Business

(Government/ Teaching/ Business/ Professional/ Government Employment/ Private Employment /
Housewife/ Student/ Others)

(c) If ‘others’ selected, please specify

9(a) *Educational qualification Bachelor's degree

(Primary education/ Secondary education/ Vocational qualification/ Bachelor's degree/
Master’s degree/ Doctorate or higher/ Professional diploma/ Others)

(b) If ‘others’ selected, please specify

10*Date of birth (DD/MM/YYYY)

20/01/1981

11*Gender

Male Female Transgender

12 Income-tax permanent account number AZHPG4088N

Income tax PAN attachment PAN CARD.jpg

13*Do you have Aadhaar? Yes No

14 Aadhaar number 649371090996

Aadhaar number attachment

AADHAR FRONT.jpg

15 Voter’s identity card number

Voter’s identity card attachment

16 Passport number

Passport attachment

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17 Driving license number

Driving license attachment

18 Permanent residential address

*Address Line 1 56,DIGVIJAY PLOTNA CHEDA

Address Line 2 VIRANI MENTION DANGARVADA

*Country India

*Pin Code/Zip Code 361005

*Area/Locality Digvijay Plot

*City Kalavad

District Jamnagar

*State/UT
Gujarat

*Jurisdiction of Police Station

DIGVIJAY PLOT POLICE STATION

19 (a) *Phone 99******52

(b) Fax

(c) *Mobile (with Country code) +91 99******52

*Enter OTP for Mobile Number

(d) *E-mail ID go************il.com

*Enter OTP for E-mail ID

20 *Whether present residential address is same as permanent residential address Yes No

21 Present residential address

*Address Line 1 56,DIGVIJAY PLOTNA CHEDA

Address Line 2 VIRANI MENTION DANGARVADA

*Country India

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 *Pin Code/Zip Code
361005

*Area/Locality
Digvijay Plot

*City
Kalavad

District
Jamnagar

*State/UT
Gujarat

*Jurisdiction of Police Station DIGVIJAY PLOT POLICE STATION

22 (a) *Phone 99******52

(b) Fax

Attachments

(a) *Proof of residence of applicant AADHAR FRONT.jpg

(b) Optional attachment(s) - if any AADHAR BACK.jpg

Verification

I, * HIMATLAL RAMJIBHAI GORI son/daughter of * RAMJI MANGALDAS GORI born on*

20/01/1981 (DD/MM/YYYY) resident of * 56,DIGVIJAY PLOTNA hereby confirm and verify

CHEDA,VIRANI MENTION
DANGARVADA,Digvijay
Plot,Kalavad,Jamnagar,Gujarat,In
dia 361005

I hereby confirm and declare that:

a) The photograph and documents being attached to the Form DIR-3 belong to me. I further confirm that all required documents
have been duly certified by the respective government authority and are being attached to the said Form DIR-3,

b) I am not restrained, disqualified, removed of , for being appointed as Director of a company under the provisions of the
Companies Act, 2013 including sections 164 and 169,

c) I have not been declared as proclaimed offender by any Economic Offence Court or Judicial Magistrate Court or High Court or
any other Court,
d) I also declare that:-

I am not required to obtain the security clearance from the Ministry of Home Affairs, Government of India under sub-rule
(1) of rule 10 before applying for director identification number; or

I am required to obtain the security clearance from the Ministry of Home Affairs, Government of India under sub-rule (1)
of rule 10 before applying for director identification number and the same has been obtained and is attached,

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e) I have not been already allotted a Director Identification Number (DIN) under section 154 of the Companies Act, 2013,

f) I further declare that I have read and understood the provisions of Sections 154, 155, 447 and 448 read with Sections 449, 450
and 451 of the Companies Act, 2013, and

g) I solemnly declare that the declaration given herein as stated above are true to the best of my knowledge and belief and that it
conceals nothing and that no part of it is false.

* To be digitally signed by Applicant

DIN1

Certification

*I declare that I have satisfied myself about the identity of the applicant based on the perusal of the original of the
attached document.
Note: In case where the applicant is residing outside India the particulars have to be verified from the documents duly
attested by the attesting authority as prescribed.
*I also declare that the company/LLP intends to appoint the applicant as a director/ designated partner after allotment of DIN

*I further certify that:

*All the required attachments have been completely and legibly attached to this form;

*I have kept a copy of this form and attachments thereto, in my records for future reference.

*It is understood that I shall be liable for action under Section 449 of the Companies Act, 2013 for wrong certification, if
any found at any stage.

* To be digitally signed by
DIN2
07181992

*Category (Director/Company Secretary/Manager/CEO/CFO/Designated partner) Director

*DIN/DPIN of the Director/Designated partner or PAN of the Manager or CEO or 0*1*1*9*

CFO; or membership number of Company Secretary

*Corporate Identity Number (CIN) / FCRN/

LLPIN/ FLLPIN with which the authorised signatory is U52100GJ2015PTC085030
associated and in which the applicant is proposed to be a director/designated partner

*Name of Company/ foreign company/ LLP/ foreign LLP CHEERFUL HEALTH SOLUTIONS
PRIVATE LIMITED

Note: Attention is drawn to provisions of Section 448 and 449 of the Companies Act, 2013 which provide for punishment for

false statement / certificate and punishment for false evidence respectively.

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For Office use only:

eForm Service request number (SRN) AA9388156

eForm filing date (DD/MM/YYYY) 20/07/2024

Digital signature of the authorizing officer

This eForm is hereby approved

This eForm is hereby rejected

Date of signing (DD/MM/YYYY)

OR

This eForm has been taken on file maintained by the Registrar of Companies through electronic mode and on the basis of
statement of correctness given by the filing company.

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