Aaaa
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Only 'Individuals' to affix recent colour photograph (3.5 cm x 2.5 cm) Sign or Left Thumb Impression across this photo Only 'Individuals' to affix recent colour photograph (3.5 cm x 2.5 cm) Sign or Left Thumb Impression Request For New PAN Card Or / And Changes Or Correction in PAN Data Permanent Account Number (PAN) C C Q P S 3 5 1 4 K Please read Instructions 'h' & 'i' for selecting boxes on left margin of this form 1 Full Name (Full expanded name to be mentioned as appearing in proof of identity/address documents: initials are not permitted) Please select title, as applicable Shri Smt. Kumari M/s Last Name / Surname A N K I T A First Name Middle Name P A N D E Y Name you would like it printed on the PAN card P A N D E Y A N K I T A 2 Father's Name (Only 'Individual' applicants: Even married women should fill in father's name only) Last Name / Surname D E V E N D R A First Name K U M A R Middle Name S H A R M A 3 Date of Birth/Incorporation/Agreement/Partnership/Trust Deed/Formation of Body of Individuals or Association of Persons Date Month Year 1 5 0 6 1 9 8 6 4 Gender (for Individual applicants only) Male Female (Please tick as applicable) 5 Photo Mismatch 6 Signature Mismatch 7 Address for Communication Residence Office (Please tick as applicable) Name of office (to be filled only in case of office address) Flat/Door/Block No. H O U S E N O . 1 3 4 Name of Premises/Building/Village S A I B A G H C O L O N Y Road/Street/Lane/Post Office K H A N D W A R O A D Area/Locality/Taluka/Sub-Division I N D O R E Town/City/District State/Union Territory Pincode/Zipcode Country Name MADHYA PRADESH 4 5 2 0 0 1 INDIA 8 If you desire to update your other address also, give required details in additional sheet 9 Telephone Number & Email ID details Country Code Area/STD Code Telephone/Mobile Number 9 1 9 9 8 1 8 1 0 4 5 4 Email ID [email protected] 10 AADHAAR number (if allotted) 11 Mention other Permanent Account Numbers (PANs) inadvertently allotted to you PAN 1 PAN 3 PAN 2 PAN 4 12 Verification I/We PANDEY ANKITA , the applicant, in the capacity of HERSELF do hereby declare that what is stated above is true to the best of my/our information and belief. I/We enclosed 4 (number of documents) in support of proposed changes/corrections. Place INDORE D D M M Y Y Y Y Date 0 2 0 1 2 0 1 4 Signature or Left Thumb Impression of Applicant (inside the box) Page 1 of 1 / A0141695
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Transcript of Aaaa
Only 'Individuals'to affix recent
colourphotograph
(3.5 cm x 2.5 cm)
Sign or Left Thumb Impressionacross this photo
Only 'Individuals'to affix recent
colourphotograph
(3.5 cm x 2.5 cm)
Sign or Left Thumb Impression
Request For New PAN Card Or / And Changes Or Correction in PAN Data
Permanent Account Number (PAN)C C Q P S 3 5 1 4 K
Please read Instructions 'h' & 'i' for selecting boxes on left margin of this form
1 Full Name (Full expanded name to be mentioned as appearing in proof of identity/address documents: initials are not permitted)Please select title, as applicable Shri Smt. Kumari M/s
Last Name / Surname A N K I T AFirst NameMiddle Name P A N D E Y
Name you would like it printed on the PAN cardP A N D E Y A N K I T A
2 Father's Name (Only 'Individual' applicants: Even married women should fill in father's name only)Last Name / Surname D E V E N D R AFirst Name K U M A RMiddle Name S H A R M A
3 Date of Birth/Incorporation/Agreement/Partnership/Trust Deed/Formation of Body of Individuals or Association of PersonsDate Month Year1 5 0 6 1 9 8 6
4 Gender (for Individual applicants only) Male Female (Please tick as applicable) 5 Photo Mismatch 6 Signature Mismatch 7 Address for Communication Residence Office (Please tick as applicable)
Name of office (to be filled only in case of office address)Flat/Door/Block No. H O U S E N O . 1 3 4Name of Premises/Building/Village S A I B A G H C O L O N YRoad/Street/Lane/Post Office K H A N D W A R O A DArea/Locality/Taluka/Sub-Division I N D O R ETown/City/DistrictState/Union Territory Pincode/Zipcode Country Name
MADHYA PRADESH 4 5 2 0 0 1 INDIA 8 If you desire to update your other address also, give required details in additional sheet 9 Telephone Number & Email ID details
Country Code Area/STD Code Telephone/Mobile Number9 1 9 9 8 1 8 1 0 4 5 4
Email ID [email protected] 10 AADHAAR number (if allotted)
11 Mention other Permanent Account Numbers (PANs) inadvertently allotted to youPAN 1 PAN 3PAN 2 PAN 4
12 Verification I/We PANDEY ANKITA , the applicant, in the capacity of HERSELF
do hereby declare that what is stated above is true to the best of my/our information and belief.I/We enclosed 4 (number of documents) in support of proposed changes/corrections.
Place INDORED D M M Y Y Y Y
Date 0 2 0 1 2 0 1 4Signature or Left Thumb Impression of
Applicant (inside the box)
Page 1 of 1 / A0141695
