Annexure-S1

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Application for Allotment of Permanent Retirement Account Number (PRAN)
(To avoid mistake(s), please follow the accompanying instructions and examples carefully before filling up the form)
To affix recent
Coloured
photograph
(3.5cm x 2.5
cm)

Acknowledgement No.
(To be filled by FC)
Permanent Retirement Account Number :
(To be filled by FC after PRAN generation )
Sir/Madam,
I hereby request that a permanent retirement account number be allotted to me.
I give below necessary particulars :

Signature/Left Thumb
Impression
of Subscriber in black ink

Section A - Subscribers Personal Details ( * Indicates Mandatory Field)

1.

Full Name (Full expanded name: initials are not permitted)

Please Tick as applicable,
Shri
Smt.
Kumari

First Name*
P R A V I N B H A I
Middle Name
K A R A S A N BH A I
Last Name
P A T E L
2. Gender * Please Tick as applicable,
3. Date of Birth *

0
D

Male

Female

2 0 5 1 9 8 3
4. PAN
D M M Y Y Y Y (Date of Birth to be certified by DDO)

5. Fathers Full Name:

First Name*
K A R A S A N B H A I
Middle Name
B E C

HA R B H A I

Last Name
P A T E L
6.Present Address:
Flat/Unit No, Block no.*
8/3
N E W C
S T A F F Q U A R T E R S

S K N A G A R

Name of Premise/Building/Village
S D

A G R I C U L T U R A L

U N I V

Area/Locality/Taluka
S A R D A R K R U S H I N A G A R
District/Town/City *
B

A N A S K A N T H A

State/Union Territory *
G U J A R A T
Country *
I N D I A
Pin Code *

7.Permanent Address: If same as above, Please Tick

Flat/Unit No, Block no.*
AT & PO - C H A N G W A D A
Name of Premise/Building/Village

else,

R S

I T Y

A W S

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P A T E L V A S
Area/Locality/Taluka
TA - V A D A G A M
District/Town/City *
B

A N A S K A N T H A

State/Union Territory *
G U J A R A T
Country *
I N D I A
Pin Code *

8. Phone No. *
9. Mobile No. *

STD Code
9 1 9

Phone No
2 2 1

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10. Email ID
p k b h u

t @ y

a h

o o

o m

11. Subscribers Bank Details (Please refer instruction no. 4)

Savings A/c

Current A/c

Bank A/c Number

3 0 1 8
Bank Name

2 8

2 0

S T A T E
Bank Branch

2 1

B A N K

OF

I N D I A

P A L A N P U R
Bank Address
S U P E R

M A R K E T

Pin Code *

Bank MICR Code

8
3

5
8

5
5

0
0

12. Value Added Services:

O P P

. O L D

G A N J

B A Z A R

P A L AN P U R

1
0

(Wherever applicable)

i) SMS Alert:

Yes

No

ii) Email Alert:

Yes

No

I PATEL PRAVINBHAI KARASANBHAI, the applicant, do hereby declare that what is stated above is true to
the best of my information & belief.
Date :
D D M M Y Y Y Y

Signature/Left Thumb
Impression of Subscriber

Section B - Subscribers Employment Details to be filled and attested by DDO (All Details are Mandatory)
1. Date of Joining

1
D

2 0 7 2 0 1 5
D M M Y Y Y Y

2. Date of Retirement

3. PPAN

3 1 0 5 2 0 4
D D M M Y Y Y

2
Y

(Please refer to instructions No. 5)

4. Group of the Employee (Please Tick)

Group A

Group B

Group C

Group D

5. Office
G N P A T E L
C O L L E G E
T E C H N O L O G Y
6. Department
S

OF

A G R I C U L T U R A L

D A I R Y

UN I V E R S

S C I E N CE

&

F O O D

I T Y

7. Ministry
A G R I C U L T U R E

8. DDO Registration Number

&

C O - O P E R A T I O N

9. DTO Registration Number

(Please refer to instructions No. 6.)

10. Basic Salary

11. Pay Scale

5 2

0 0

0 2

0 0

G P

2 4

0 0

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Certified that the above declaration has been signed / thumb impressed before me by
PATEL PRAVINBHAI KARASANBHAI
after he / she has read the entries / entries have been read over to him / her by me and got confirmed by him / her. Also certified that the date of
birth and employment details is as per employee records available with the Department.

Rubber Stamp of the DDO

Signature of the Authorised Person
Designation of the Authorised Person : DDO
Date :
D D M M Y Y Y Y

Name of the DDO :

Department/Ministry:

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Section C - Subscribers Nomination Details (* Indicates Mandatory Field for nominee)
1. Name of the Nominee *:
1st Nominee

2nd Nominee

First Name *

3rd Nominee

First Name *

First Name *

Middle Name

Middle Name

Last Name

Last Name

R A M I L A B EN
Middle Name
P R A V I N B HA

Last Name
P A T E L

2. Date of Birth (In case of a minor)*:

1st Nominee
0 1 1 0 1

9 8

2nd Nominee

3. Relationship with the Nominee*

1st Nominee
W I F E

4. Percentage Share *:
1st Nominee

3rd Nominee

2nd Nominee

0 %

5. Nominees Guardian Details (in case of a minor)*:

1st Nominees Guardian Details
First Name *

2nd Nominee

3rd Nominee

3rd Nominee

2nd Nominees Guardian Details

First Name *

3rd Nominees Guardian Details

First Name *

Middle Name

Middle Name

Middle Name

Last Name

Last Name

Last Name

6. Conditions rendering nomination invalid:

1st Nominee

2nd Nominee

3rd Nominee

Section D - Subscriber Scheme Details - NA

1st Scheme
Pension Fund Managers Name/Code

Scheme ID No./Name

Percentage Share
%

2nd Scheme
Pension Fund Managers Name/Code

Scheme ID No./Name

Percentage Share
%

3rd Scheme
Pension Fund Managers Name/Code

Scheme ID No./Name

Percentage Share
%

Section E Declaration
I understand that there would be PFRDA approved Terms and Conditions for Subscribers on the CRA website governing
I-Pin (to access CRA / NPSCAN and view details) & T-pin. I agree to be bound by the said terms and conditions and
understand that CRA may, as approved by PFRDA, amend any of the services completely or partially without any new
Declaration/Undertaking being signed.
I PATEL PRAVINBHAI KARASANBHAI the applicant, do hereby declare that what is stated above is true to the best of
my information & belief.
Date :
D D M M Y Y Y Y

Signature/Left Thumb
Impression of Subscriber

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