UNNI es Le St LS |Paymont Date: ——— [appicaion Sowce-EWALLET “A - CSC E GOVERNANCE SERVICES INDIA LIMITED ——lappication oat GS/000008 — ser ta [722577 260012 Juser Name:[722517260012 PAN CARD MODE : Both physical PAN and e-PAN Card [Application Mode = Physical Application Form No. 494 Application for Allotment of Permanent Account Number [inthe ease of indian Citizens! Indian Companies! Entities incorporated in Unincorporated entities formed in India} BONG: Ive nor request mata aarmanent account Number be alte to melus ! 1 Full Name (Full expanded name to be mentioned! as appearing in prod! of Klontityladéress documents: intale are not permed) ; we [Yas apptcane [7] so Joo aman [Jos Name Sur 2 22RD ORS eee eee 5 CE RANMA TOE | | Fol last 2. Abbreviations of the above name, a8 you would Ike Wf tobe minted onthe PAN card MOHAMMAD. AYIA N| | eee oth crane ves [no (Plaee tick as applcbie wsmprcnse [fs (fs oman ue 44 Gender (fr insividual applicants only) YZ] mae Female Transgender (please ick as applicable} 3. Date of Sithincorparation/Agreement/Partnership oF Trust Deed Se mane a Formation of Body of individuals or association of Persons G4) Gi) [2fetere 6 Details of Parents (applicable only for individual applicants) \Wieter motes a enale parent and you wshto appl or PAN by turishing ne name of your mother onl? Yes _] No[Y] (ease tick as appkcabie ityes, pease flin mother's name nthe appropriate space provided below Father's Name (Mandatory except where mother isa single parent and PAN is applied by furnishing the name of mother only) asi . SALEEM ere ‘ MOHAMMAD I MIOUHAIMIM/AO} UP po} et || vite Pr tii i i ‘Mothors's Namo (optional xcept whore mother Ie @ single parent and PAN ie appli by furnishing the name of mother only) Seinc no name ih oy ik to Be ped on PAN ca ci {incase no onto provided ten PAN cara wie ese wh ters ame exceptwnere moter ange par’ and you wih to apy or PAN fuming ame otter ony) [7] ators rane [_] Moors Namo Pant put 7 Adaress Residence Address ‘Rec Door Bock Na [A‘D|_S|A/L[ETE/M ARIE WAN. ss mee Mik | ee.) 7 UTTAR PRADESH INDIA Once heaaael name oe ee TT a Coot BN | ial ve al 2c Street Lane Post ome I 1 ha‘Area Locality Tanna Sub-Omson [| : 8 Adsress for Communication [7] Residence otice {Pease tick as applicable) 9 Telephone Number & Email ID details County cove —__AreatSTD Code Telephone / Mobile number {9]a 7/3]7/9 17/35 10]o/2 © |nensupremegoti@ gma fms, LLPS ete) ae ete EP iisisedeb sais case ot pron ven raged 0 qt Aaa ube ErroertD of echt appenton frm ay er acon 198A ae Aonaen nomen pact = [15 [6] CS 1317t (1 2LeL tae tern ata pans mentan he evanent 1D of Anaarapicaton rm MPO TALeTPIUL TelALe| eel Iwierel 1] ‘]aolziol2ia Name as pet AADHAAR letter! ‘card oF as per the Enrciment 1D of Aadhaar application form wiolnlalM[wialol [AlYiAINT_| 1] eet + 414 Registration Number (for company, 43. Source of income Please select. [Vas apiica DO se (income om House rope YZ] wo ncome DD cant Ta Reprecenave arenas (RA) apenas A pans. uo meni ut ts oA pec ibe pa ae Peruana expanded came sl ar not ported) ne asepmane (gem fej fina | []s slate =|™. | Fist [wlo #|a MM A/D Soe eotaseonem {|_| bean ptt narcene! [7] nea ton one sores A ution ayeyeter| 11 Nn ooorane cundegiiimae peer Seal == a me SEE D. Tod non cet ndiaieietmmen (iz2)a'e [a ea ]D Tiel : 2 jalz alw ola R/# I ime on To pee eo es oa [rle[s [els] lemme Asbo amens submited a8 Proof of Mentiy (POD, Prot af Address (POA) and Proof of Date of Birth (OO) wenmecnooa AADHAAR Card issued by 2 so! wonty |KADHAAR Card issued by UIDAI ee a AADHAAR Card issued by VIDA! ae oo vc yumm wgronesn fue 14 Pes, 082)" tf manta cts gosumas esa fa conus Anon 8-& Amana Caro te ved wherver apical te ie MOHAMMADAYAN |. pcan nt apn HIMSELF/HERSELF ‘donereby eaclare that whats stated above is rue tothe est of my/our information and Povey ot i ate as fiir‘aVHTaa BA Eorolment No.: 0871/27641/09469 or ae sts mY Fer ec oy [Link]. sams Me aT fap ase eer Pet oF Sm : aS ar rats / Your 9496 5137 9187 ‘i 915707466863 3612 Pease eeeeT seer Taree aa wean Unis Identification Authonty of inci 2 see oe Government of Inia sess 222 = aa (iar des 276305, 9496 5137 9187 " Coes aa see, At deat = ae => Address: S/O Mahammad Shahid, i yet / MALE ay sere acihy Mohammad Saleem orem far / DOB: 17/08/1984 8890 6669 6866 ar arene, Af Gea sreee feiss tear waft Ses OF INDIA a sinesie eft, a, eer amik jarewan, Serai Meer, #R, sing, Zamgarh, Uttar Pradesh - ‘SAR we - 276305 = 8890 6669 6866 we " Bengalurus60 00%