Request For New PAN Card Or/ And Changes Or Correction in PAN Data
Only ‘Individuals’ to affix Only ‘Individuals’ to affix
recent photograph recent photograph
(3.5 cm × 2.5 cm) Permanent Account Number (PAN) (3.5 cm × 2.5 cm)
F SJ PB6244K
Please read Instructions ‘h’ & ‘i’ for selecting boxes on left margin of this form.
Signature / Left thumb
impression across this photo
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
Signature / Left thumb impression
Last Name / Surname B A N O
First Name N A J R E E N
Middle Name
Name you would like it printed on the PAN card
N A J R E E N B A N O
2 Details of Parents (applicable only for Individual applicants)
Father’s Name (Mandatory. Even married women should fill in father’s name only)
Last Name / Surname
First Name B A J R U D DI N
Middle Name
Mother’s Name (optional)
Last Name / Surname
First Name
Middle Name
Select the name of either father or mother which you may like to be printed on PAN card (Select one only)
(In case no option is provided then PAN card will be issued with father’s name) ✔ Father’s Name Mother’s Name (Please tick as applicable)
3 Date of Birth/Incorporation/Agreement/Partnership/Trust Deed/ Formation of Body of individuals or Association of Persons
Day Month Year
0 2 0 4 1 9 9 2
4 Gender (for ‘Individual’ applicant only) Male ✔ Female Transgender (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/Room/ Door / Block No. F - 3 4
Name of Premises/ Building/Village B L O C K - F
Road/Street/ Lane/Post Office G A L I N O 3
Area / Locality / Taluka / Sub- Division J A I T P U R E X T N P A R T 2
Town / City / District B A D A R P U R
State / Union Territory Pincode / Zip code Country Name
NEW DELHI 1 1 0 0 4 4 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
0 9 1 9 8 1 8 1 4 1 3 2 4
Email ID
[email protected] 10 AADHAAR number (if allotted) 8 8 8 3 8 5 3 6 2 7 4 2
Name as per AADHAAR letter/card
N AJ RE E N BANO
11 Mention other Permanent Account Numbers (PANs) inadvertently allotted to you
PAN 1 PAN 2 PAN 3 PAN 4
12 Verification
I/We NAJREEN BANO , the applicant, in the capacity of HIMSELF/HERSELF do hereby
declare that what is stated above is true to the best of my/our information and belief.
I/We have enclosed 1 (number of documents) in support of proposed changes / corrections.
Place BADARPUR
D D M M Y Y Y Y
Date Signature / Left Thumb Impression of
0 5 0 6 2 0 2 5 Applicant (inside the box)
