8.
If you desire to up date your other address also, give required det ails in additional sheet.7.
Address for Communication Resident Office (Please tick as applicable)5. Photo Mismatch
6. Signature Mismatch4. Gender (for Individual applicant
s only) Male Female (Please tick as applicable)3. Date of Birth / Incorporation/Agreement/Partnership or T
rust Deed / Formation of Body of individuals or Association of Persons (DD / MM /
YYYY) 1. Full Name
(Full expanded name to be mentioned as appearing in proof of identity/address doc\
ument s:initials are not permitted)
Please Select Title as applicable Shri Smt. Kumari M/s Last Name / Surname
First Name
Middle Name
Name you would like it printed on the P
AN cardName of Of
fice (to be filled only in case of of fice address)
Flat/Room/Door/Block No.
Name of Premises/Building/V illage
Road/S treet/Lane/Post Of fice
Area/Locality/T aluka/Sub-Division
T own/City/District
St ate/Union Territory P
U N J A B PIN
Code
I N D I A CountryLast Name / Surname
First Name
Middle Name 2. Father
’s Name (only ‘Individual’ applicants : Even married women should fill in father ’s name only) 9. T
elephone Number & Email ID det ailsCountry Code Area/STD Code T
elephone / Mobile Number +
9 1 Email ID
10. AADHAAR number (if allotted)1
1. Mention other Permanent Account Numbers (PANs) inadvetently alloted to youP
AN 1 PAN 2
I/W e \
the applicant, in the cap acity of
fo hereby declare that what is st ated above is true to the best of my/our information and belief.
I/W e have enclosed (number of document s) in support of proposed changes/corrections. Signature/Lef
t Thumb Impression of Applicant (inside the box)Place :
Date :
2 0
1
12. V
erification
Branch ID : 02565
(07/08/2015)
Request for New P AN Card or / And Changes
or Correction in P AN Data
Permanent Account Number (P AN)
Signature/Left Thumb Impression across this photo Signature/Lef
t Thumb Impression Only ‘Individuals’
to af fix recent
photograph
(3.5 cm X 2.5 cm) Only ‘Individuals’
to af fix recent
photograph
(3.5 cm X 2.5 cm) Please read Instructions ‘h’ & ‘i’ for selection boxes on
left margin of this form. TIN FC - CODE - 02565