r [Avice Nurbor(AO636 76564 i a WOUOUUU A MIN (ms 2ST | A 7 SS Npaymont oate: _[14712/2022_R8.107.00- I |Anoicaion Source: [EWALLET - A20 - PAYWORLD DIGITAL SERVICES PRIVATE LI/ITED_lapplcation bate (1272022 (627321338 User Neme:[42732 1338 —— a) [PAN CARD MODE _ Both physical PAN and e-PAN Gard [Application Mode , Physical AI Form No. 490 ‘Application for Allotment of Pormanont Account Number lin the ease of indian Chizons/ Indian Companies! Eniiies incorporated in india! Unincerperated entities ormed in india} eo Rule tte | ‘Wend mites ema toone susnpstyegnemtbesandname sie tig im |Assossing officer (AO code) ‘aa code ‘Ove [Range code | AO. s[niw 4 6 ~ | are ree tS cnt nie rot Aria benena iW give below necessary parteulrs {>a 1 Full Name (Full expanded name tobe mantioned as appearing in pto0! of Wenttyladcress documenis nilals are not permited) Plesse selectite [V]es epptcable []sna [x] Smt kuman [|e Last Name 1 Summame BIE[H[E|RIA I TTT TT Frat Nae Alelalelal | me rT 1 | 2 Ab of a would ike it, tobe prinied on the PAN card AIBIAICIAT IB [E|NIEIRIA T T LEI I I 3 Have you ever been known by any other name? ves [x]no (please fick as opplicabie) i ye. pence geo ter ame | Ploase select tte, [yas epptcable Jsna CJs~. Ikumant hats Last Name /Sumame I FistNome iste Name To Te 4 Ganda for dat gpa ony Efvate — (e)remete[_Jenogonder (sane kes apptiate) Day Mon eee © Someseasl Segyarichaccasevseesoaion cr Parara. (id) [of2) Hetero 1S Detalls of Parents (applicable only for Individual applizants), Vineter mother's 2 angie parent an you wish to apply for PAN by furishirg the nane your mother onl? Yes ityes. please fin mothers name nthe appropriate space provided below Father's Name (Mandatory except where mother isa single Last Name | Sumame BIE] Fist Name Miasie Name Mothers's Name (optional except where mothers «single Last Name / Sumamne I eae “TEL EEE ‘Sclect he name of other father or meter whlch you may The We ba patted on PAN card aoe oah (ln cate ro option is provided then PAN card wilbe issued vith fathers neme except where moter Pasi amsneg name fine rater ni) [ye] Fatrers name [_] Meters Nama reves nants 7 paceoes Rastdonee Desees OfoveiLfeT InJelT RJojo|m] [NJoy [i]2 irene) Terr PATE uty] MiAlR| Kel] clM[P|tlx AlT|O[ TIA Name of Premises / uid | Voge HleElR ale Rood Steet /Lane/Post Ofico ‘Area | Local [Tauha/ Sub. Dison Town Cty / Deine. ‘Sate / Union Tomiory Precode /2ip code ‘County Nano. ODISHA 7/5 [8 [4 JoloT | INDIA J PAE o zi>[>/e ja Office Address Name of tee Fat (Room / Door / Block Ho. Name of Premises /Buicing/ Vilage‘Aron/Localty Tait Sub- DMsion ‘Town / Cty /Distiet, be 8 Address for Communication 9 Telephone Number & Email ID deta Countycase AnaSTDCade Thlephone Motte uber 3] I TBls[elelels fll TL Email [email protected] {0 Situs of aplcant Please sect tas, [V7] 8 pptcatle Hsin ecu navies try ]company Pavers Fem tome eoiyottetiits — E]lccat auton arta ric! Penont {1 Registration Number (or company, firms, LLPS ate) I 42m Case of a person, who is required to quote: Preese mention your AADHAAR number ( aleties) [8 | 8 HARDHAAR number isnot alloted, please mention te env ‘Aachaar number/The Enroimant D of Aachsar application form as per tection 13988 ale] [a[>Je]4 (lelals iment D of Aachaar applteation form Government Association cf Person Limited Liaity Parnershio Namo as per ADHAAR ltiaricard of aa per the women ID ofAadhaar epplicalion frm BlELHIE, RIA AIBJAILIAl { + [2 T] 43. Source of Income CD say 1 income teen Business Profession ‘14 Representative Assessee (RA) Full nme, address of the Representative Assessce, nho is assessiie| Deon given in the column 1-13. Full Name (Full expanded name : Initials are not permittee) T7 income rom House property ushessPtessn cose [ Preose sotet. [7] 28 applicable No income: Prease selec ile, [7] es epplcable sh sat CO copia cans {For Code: Rater ntrctere] [_] income tom Other source ‘Under the Income Tax Ac in respect ofthe person, nhose partculars have Last Name / Suma Fret Name Midge Name Address Flat eoom / Door | lock No. Name of Premises / Building / Vilage Rood Steet /Lane!Post Ofice ‘Avea Locality / Taluka! Sub- Onision Town / Ciy/ District ‘State / Union Terry Pecoae 15 Documents submitted as Proof of identity (PON, Proof of Address (POA) and Proof of Date of Bich (008) [Pease retort the Instucions (98 speciied in Rule 114 of. Rules, 1962) fer Ist of markatoy cored documents 10 be submited 28 appicabie| fAmenure A Aanexur0 8 & Annousre C ae io be used wherever oppfcablo} se ER) {25 proof of dae of bith, the applicant Inthe capacly of 2 prot tisouy, PADRARR Cards by UAT IMSELF/HERSELF +) onereby dectare that wnat is stated above ts tue (0 the best of my/our information and belo Pace — [TALCHER pM 4a] Fegan Benen “Signature /Laf Tham impression of Appicont (nai the box)iB AADHAAR AIAG AAGIA = reas aed gana 260. e@Seo god! = atone gre 29 cing asateoer 18199 60g) 1 Enrollment No. 1040/10777/16716 INFORMATION ® Aadhaacis proof of identity, not of citizenship © To establish identity, authenticate online le e210 araicogca coy | le s@evesa WE cia, ens aaciars ceaamer | 620 2:9 CSaIES AIRIAe ERG! | {= Aadhaar is valid throughout the country . | MAAS" LA Aes (Your Aadhaar No. : 8886 1984 7614 Al = AUQE AMIGA ATER l= Aadhacr will be hoipful in availing Government and Non-Government services in future - aaoassa Se ry ‘Government of India pe errenaamiata yo i AENABEHERA diese Gane ewiccieain “Momaiuinin foes An oDanA Tome cane Beene tenorye gee 08 ove 9H sofa Satan 8886 1984 7614 z alia — ARGS SRIGA AYIA = 8881884 rod Abate Lehesa sos eye kumoy AS Hise Gqy OO