Acknowledgement Number : N- 881031204715406

Only Individuals to
affix recent
photograph
(3.5 cm x
2.5 cm)

Request For New PAN Card Or/ And Changes Or Correction in

Only Individuals to
affix recent
photograph
(3.5 cm x
2.5 cm)

Permanent Account Number (PAN)

BDPPK5686K
Please read Instructions h & i for selecting boxes on left margin of this form.

Sign/ 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)

Shri

Please select title, as applicable

Smt

Kumar

Signature / Left Thumb Impression of

Applicant (inside the box)

M/S

KHATKALE

Last Name/Surname
First Name
Middle Name

PRAVIN

BALASAHEB
Name you would like it printed on the PAN card
PRAVIN BALASAHEB KHATKALE
2 Details of Parents (Applicable only for Individual Applicants)
Father's Name (Mandatory , Even married women should fill this)
Last Name/Surname
KHATKALE
First Name
BALASAHEB
Middle Name
SOPANRAO
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

3. Date of Birth/Incorporation/Agreement/Partnership or Trust Deed/ Formation of Body of individuals or association of Persons

Day

Month

Year

17/07/1986
4. Gender(for individual applicants only)

Female

Male
6.Signature Mismatch

5. Photo Mismatch
7. Address for Communication

Office

Residence

Name of office
Flat / Room / Door / Block

ANNAPURNANAGAR

Name of Premises / Building /

BAGULVASTI

Road / Street / Lane/Post Office

STATION ROAD

Area / Locality / Taluka/ Sub-

KOPARGAON

Town / City / District

State / Union Territory
MAHARASHTRA

KOPARGAON
PIN Code
423601

ZIP Code
null

Country
INDIA

Pincode
/ Zip
codeIn additional sheet.
8. If you desire to update your other address also, give
required
details
9. Telephone Number & Email ID details
Country

Telephone / Mobile

Area/STD Code

9975717140

91
Email ID

PRAVEENKHATKALE@GMAIL.COM

10. Please mention your AADHAAR number (if allotted)

518408785419

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

PAN

PAN

PAN

12. Verification
I/We

the applicant, in the capacity

PRAVIN BALASAHEB KHATKALE

Himself/Herself

do hereby declare that what is stated above is true to the best of my/our information
belief.
I/We have enclosed

(number of documents) in support of proposed

changes/corrections.
Place

Date

KOPARGAON
DD
MM
14/11/2016

YYYY

Signature / Left Thumb Impression of

Applicant (inside the box)

13. Other Address :

Name of office
Flat / Room / Door / Block
Name of Premises / Building /
Road / Street / Lane/Post Office
Area / Locality / Taluka/ SubTown / City / District
State / Union Territory

PIN Code

ZIP Code

Country

Signature / Left Thumb Impression of

Applicant (inside the box)