Payment Reference:(4103 165826776685 | PYO128643439 CU eee ASS290 7 50S |payment Date: foro4/2024 Rs i0700- ————i{ application Source: [EWALLET- A - CSC E GOVERNANCE SERVICES INDIA LIMITED Application Date:(12/04/2024 _] User [235514220019] User Name: (335574220019 - | PAN CARD MODE : Both physical PAN and e-PAN Card [Application Mode = Physical Application Form No, 494 ‘Application for Allotment of Permanent Account Number lin the case of indian Citizens! Indian Companies! Entities incorporated in Indial “Unincorporated nites formes in ni Ps — Sen use 4 Assessing officer (AO code) ea coo ll earpe ante (PO | ele lilw ral ole] Sir /We hereby request that 9 Permanent Account Humber be ated 10 me/us. | We give below necessary particulars 4, Full Name (Full expanded name to be mentioned 3s appearing in proo pres wectie [7 ansnpicave [e]sm [Jom [_]euran [Je LastName Surana wlelelNjal | | CoC Frame D/HIOIN T Mice Name CL 2 rota ote shove nen 5 DHONI, ME EN Al “EEE 3 tae you oe be el Proce saccite [7Josoricase [TJsm [Jom [rumen [Je known by any other name? Last Name / Surname L la 1 jt ti 4 Fir Name [ Tor I 7 Misde Name CCOererrt “COC 4 Gender (or individual applicants only) [Z)mate — ]remate Transgender (please tick as applicable) oxy Month 5 bate of BinisincoporaionAgreementPartnership or Trust Deed! = i Formation of Body of inavials or asoctation of Persons (i{s] fois) [2ToloTs {6 Details of Parents (onpicable only for individual applicants), Vitethermotheris singe parent and you wish lb apply fr PAN by fumishing the name of your mother ony? Yes[__] No[¥/] isles tek as applicable yes, please fin mother's name in the appropiate space provided below Fathers’ Name (Mandatory except where mother isa single parent and PAN s applied by furnishing th Last Name ! Sumame MJEvE[N|Al Lt 1 ~ First Name. SUHUVIRIA J I 4 Middle Name ist Ni6|H Mothors's Name (optional except where mother arent and Last Name! Sumame LI 1 Fret Name Midaie Name Tl aan Select the name of ether father or mother which you may ike fo be prinied on PAN card iacron oan (tn case no options provided then PAN card wil be issued wih fathers name except where mother is a single parent and you wish to apply for PAN by furnishing name ofthe mother nly) [y7] Fathers name [_]Mothors Name itearst ayant 7 Address Residence Address Flat / Room / Door / Block No. im I wo K|HE|D AL CiHIATLIA ciHlolp a Name of Premises Bulding Vilage Road Sweet LanaiPost Office ‘Area | Locabty/ Taluka! Sub- Dvision Town/City /Distit State / Union Tersiony [MADHYA PRADESH47/311 Office Adaress Name o tice Fiat Room /Door / Bock No, Nome of Premises /Buding Vilage Road Sir Lave Post ottce‘ea / Locality Taluka Sub- Dion fi Town | Cy Dist { mi Residence ottice (Please tick as applicable) 8 Adcress for Communiaton 5. Telephone Number § mal 0 details County cose Area/STO Coe Telephone Mobie number | CLELEID) Gels [ols lolel2 emaiio [iishwakarmavtipan@gmailcom 10 status of appicant Please select status, [Y ]as appicable |Sovernment [Y]raivicuar Hindu unaiviaed tamiy — [_]company Partnership Firm Association of Persons eusts cy of indvidvls Locat Aunorty Aric! urea Persons [7] Lites Laoity Parnersio| te) T TT] 1 1 LITT {TT Tt tit) CLT ees) te aa {2p Case ofa parson, who ls requted to quote Aadhoar numiber/The Enrolment of Aschaar application form as por section 139A Pease mentan yur ADHAAR eumbrfetones) (4 4[2] 3) (7]715]7] [3]a] 71 0} I{AADHAAR numoer sna ota, tease mention the enokment 1D ofAadhaar application fom LITITTT TT TM (a) Name as por AADHAAR itera oras patho Enrolment ID af Aahaar applzalin form fepetotet TuteTetatay Lo Litt [ [TTT ie Meee aes aes se, [7] se appt Dewy ee ata ae i hrcome tom Business Profession BusinessrPratession cose [_[__] (For Cove: Referinstuctons] Rapraenais Anant 4) ert ernie heeeee vos neti uncer oIrcare Tet epee of ha pr, ee parkas hve fen gen htacaunn Fo rn ul expanded nae: ise arent pei) Income from Other sources Pease selec te [7]3soncicave [y]sm [Jom []ruman Last Name / Suman Defoe [MJETE[NIA Fs Nome wide Name Aaress . Fat! Room Ooo tock No eee Nae ot Pemises/eutding age [STALE [RT R[ETD fRoad/Sroet/LanoPestofice [BAL Pc] HALL co. ‘eas Locaity Teta’ Sub-Dwson (C]E|Ale|A[OLo Town / City / District G{ulwtal | [ Slate / Union Terry MADHYA PRA De Ss H[é[7[3|i[2|5| |Prowae 415 Documents submitted a8 Proof of identity (POV), Proof of Address (POA) and Proof of Date of Birth (008) We have encloses | AADHAAR Card issued BY | as root ot dontiy, AADHAAR Card issi ‘as prot of address ang [AADHAAR Card issued By UIDAT ] as prot of date of bith. {Prease rele othe instructions (as spectied in Rule 114 of LT. Rules, 1962) for Sst of mandatory certified documents to be submited a8 appicable} [Annee A. Annenure 8 & Annexure Care tobe used wherever applicable] 416 Wwe [DHONI MEENA : the applicant, in he capacty of [HIMSELF/HERSELF clo hereby declare tat what Is stated above is tre 1o the best of mylour information and bet. piace. [CHACHODA 7] es ‘Signature / Leh Thumb impression of_Applicart (inside the box) |ae ATT Government of India o eh ta ; (Dhoni Mesa & ‘we FARE (008 157042008 . Fr Male 4413 7757 3170 _ Ay Reason Sere Unig Gentivcation Authority of dia arora FET FAR ae, Ades: 50: Shr Sigh oer, SHE ae, Tot oe, penton gana Ad | + Sex, yam mer, me Khu Guna Bap she Moye wa, 473118, Pate eas » 4413 7757 3170 S757 3170 z. ba ee se ei alle