Form No.

DIR-3-KYC Form language

KYC of Directors English Hindi
[Pursuant to Rule 12Aof the Companies (Appointment and Qualification of
Directors) Rules, 2014]

All fields marked in * are mandatory

In case of Indian nationals, Income-tax Permanent Account Number (Income-tax PAN) is mandatory in all cases even if there is no
change in Income-tax PAN. In such cases, director details should be as per Income-tax PAN. In case the details as per Income-tax PAN
are incorrect, director/designated partner is advised to first correct the details in Income-tax PAN

Refer instruction kit for filing the form

Director related information

1 (a) *Director Identification Number (DIN) 07332291

(b) *Name ASWINI KUMAR PUJAHARI

2 Director’s Name (Enter full name and do not use abbreviations)

(a) First name ASWINI

(b) Last name PUJAHARI

(c) Middle name KUMAR

3 Father’s Name (Married woman shall also give father’s name)

(a) First name ASWINI

(b) Last name PUJAHARI

(c) Middle name KUMAR

4 *Whether a citizen of India Yes No

5 *Nationality India

6 *Whether resident in India Yes No

7 *Date of birth(DD/MM/YYYY) 24/09/1955

8 *Gender Male Female Transgender

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 9 Income tax PAN ADXPP2830P

10 *Do you have Aadhaar Yes No

Aadhaar number 806019436040

11 Voter’s Identity card number

12 *Do you have a valid passport Yes No

Passport number

13 Driving license number

14 *Personal Mobile Number +91 ********90

15 *Enter OTP for Mobile Number 2079

16 *Personal Email ID ak************il.com

17 *Enter OTP for e-mail ID 1867

18 Permanent residential address

Do you have permanent address outsideIndia Yes No

*Address Line 1 KANDHAPALI PADA,

KANDHAPALI PADA

Address Line 2

*Country India

*Pin Code/Zip Code 767001

*Area/Locality Balangir

*City Balangir

District
Balangir

*State/UT
Orissa

*Jurisdiction of police station

BALANGIR

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 Phone

Fax

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

20 Present residential address

*Address Line 1 KANDHAPALI PADA,

KANDHAPALI PADA

Address Line 2

*Country India

*Pin Code/Zip Code 767001

*Area/Locality
Balangir

*City
Balangir

District
Balangir

*State/UT
Orissa

*Jurisdiction of police station BALANGIR

Phone

Fax

Attachments
(a) *Proof of permanent address
DOC.pdf

(b) Copy of Aadhaar Card

DOC.pdf

(c) Copy of Passport

(d) Proof of present address

(e) Optional attachment(s) -if any

Verification

I, hereby confirm and verify that the particulars given in the Form herein above are true and also are in agreement with the
documents being attached to this form.

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(i) The documents being attached to the Form DIR-3KYC belong to me. I further confirm that all required documents have been duly
issued by the respective government authority and are attached to the Form DIR-3 KYC;

(ii) I further confirm that the Mobile No and email ID belong personally to me.

(iii) I have not been declared as a proclaimed offender by any court of Economic Offences or court of Judicial Magistrate or High
Court or any other Court;

(iv) I have no other allotted DIN other than DIN in which changes are intimated under section 154 of the Companies Act,2013 or a
Designated Partner Identification Number under section 7 of the Limited Liability Partnership Act, 2008; and

(v) I shall be liable under section 447 read with section 448 of the Companies Act, 2013 and under relevant provisions of the Indian
Penal Code, 1860 and any other law as applicable, if any statement in this application is found to be false or any material fact is found
to be have been omitted.

*To be digitally signed by DIN holder

Certificate by practicing professional

I declare that I have been duly engaged for the purpose of certification/verification of this form.It is hereby certified that:

*I have satisfied myself about the identity of the DIN holder and his address based on the perusal of the original of the attached document.
Note: In case where the DIN holder is residing outside India the particulars have to be verified from the documents duly
attested by the attesting authority as prescribed.

*I have verified and attested the documents of the DIN holder based on the Originals documents produced before me.

*All required attachments have been completely attached to this application.

*I have gone through the provisions of The Companies Act, 2013 and rules thereunder for the subject matter of this form and
matters incidental thereto and I have verified the above particulars (including attachment(s)) from the original records
maintained by the Company/DIN holder which is subject matter of this form and found them to be true, correct and complete
and no information material to this form has been suppressed.

*I further certify that:

*Mobile No and email ID belong to the Director signing the form.

*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 further reference.

*It is understood that I shall be liable for action under section 477 read with section 448 of The Companies Act, 2013 for
wrong certifications, if any found atany stage.

*To be digitally signed by

*Category Company Secretary (in

(Chartered accountant (in whole-time practice), whole-time practice)
Cost accountant (in whole-time practice), Secretary (in whole-time practice)

*Whether associate or fellow Associate Fellow

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 Membership number

Certificate of Practice number 14605

Note: Attention is drawn to provisions of Section 447 read with section 448 and 449 of the Companies Act, 2013 which provide
for punishment for false statement / certificate and punishment for false evidence respectively.

For office use only:

eForm Service request number (SRN) AB1447930

eForm filing date(DD/MM/YYYY) 08/10/2024

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 director and professional.

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