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)

Signature across this photo

1 Full Name (Full expanded name to be mentioned as appearing in proof of identity/address

v/ documents: initials are not permitted)
Please select title, as applicable Shri v/ Smt Kumari M/s
Signature inside the box
Last Name / Surname K O T A
First Name S H R I J A
Middle Name R A V I K A N T H
Name you would like it printed on the PAN card
S H R I J A R A V I K A N T H K O T A
2 Details of Parents (applicable only for Individual applicants)
Fathers Name (Mandatory. Even married women should fill in fathers name only)
Last Name / Surname T
First Name D E V E N D R A N
Middle Name
Mothers 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 fathers name) v/ Fathers Name Mothers 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
20 09 1983
4 Gender (for Individual applicant only) Male v/ Female (Please tick as applicable)
5 Photo Mismatch
6 Signature Mismatch
v/ 7 Address for Communication v/ Residence Office (Please tick as applicable)
Name of Office (to be filled only in case of office address)
Flat/Room/ Door / Block No. L A N C O H I L L S
Name of Premises/ Building/Village
Road/Street/ Lane/Post Office D C 1 1 4 / 9 9 L H , M A N I K O N D A
Area / Locality / Taluka / Sub- Division
Town / City / District T E L N G A N A
State / Union Territory Pincode / Zip code Country Name
TELANGANA 5 0 0 1 0 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
+ 9 1 8 0 5 6 0 2 4 6 3 6
Email ID shrija09@gmail.com
10 AADHAAR number (if allotted)
Name as per AADHAAR letter/card

11 Mention other Permanent Account Numbers (PANs) inadvertently allotted to you

PAN 1 PAN 2 PAN 3 PAN 4
12 Verification
I/We SHRIJA RAVIKANTH KOTA , the applicant, in the capacity of Herself do hereby
declare that what is stated above is true to the best of my/our information and belief.
I/We have enclosed (number of documents) in support of proposed changes / corrections.
Place TELANGANA
D D M M Y Y Y Y
Date 1 0 1 0 2 0 1 7 Signature of Applicant (inside the box)
C - 6461053506
 INSTRUCTIONS
Please refer the following steps after Application Form is downloaded and printed.
1. Once the Application Form is downloaded you should print the same, attach your
recent, coloured Passport size (3.5cm X 2.5cm) photographs on the prescribed boxes
in the form.

Kindly Sign Across the Left photograph (signature should not be done on the face).
Sign beneath the Right Photograph in the box provided.

2. If the applicant is unable to sign and choose to put a thumb impression, then the same
should be attested by Notary on the form. Make sure that Thumb impression or
Notary stamp should not be on the right photograph.

3. Once the form is duly signed and photograph is attached on the form, it should be sent
along with self-attested document proofs for Identity, Address and Date of Birth by
Courier/Speed post to the mentioned address i.e.

The Manager,
PANIND Services Unit,
No. 5, Site 4, Vikaspuri,
New Delhi-110018
India

4. The PAN Application process would start once we receive the duly signed form along
with all the document proofs.

5. You would be intimated by an email your Coupon/Ack number after receiving the
signed application form along with ID Proof, DOB Proof and Address Proof.