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Fields marked asterisk (*) are mandatory.
PERSONAL DETAILS
Name in Full*
First Name
Middle Name
Last Name
Middle Name
Last Name
Residential Address
C/o
House No and Name*
Landmark*
State*
District*
Village/ City*
--Select--
Please Mention
Pincode*
Telephone / Landline.(With STD Code)
+91
Sex*
Male
FemaleDate of Birth*
Mobile No.*
Occupation*
Category
--Select--
Particulars of Transaction
accounts(s)*(b)
No
Yes
Educational Qualification*
--Select--
Email ID
KYC Document
151530019163
Yes
No
Army
Air Force
Other Individuals
Sir,
I/We hereby request that a permanent account number be allotted to me/us.
I/We give below necessary particulars:
* 1. Full Name (Initials are not permitted in first and last name. Applicant's proof of identity,
proof of address and proof of date of birth should contain the exact name mentioned in this
field)
Title
Shri/Mr
Last Name/Surname
Smt./Mrs.
Kumari/Ms
First Name
M/s
Middle Name
* 2. Name you would like printed on the card (Prefix like Shri, Smt, Kumari, Late, Dr, CA,
Ms, Mr, Mrs, M/s, Alias etc. are not allowed)
No
Male
* 4. Gender
Female
* 5. Date of
Birth/Incorporation/Agreement/Partn DD
ership or Trust Deed/Formation of
Body of Individuals/Association of
Persons
MM
YYYY
* 6. Father's Name (Even married women should give father's name only. Prefix like Shri,
Smt, Kumari, Late, Dr, CA, Ms, Mr, Mrs, M/s, Alias etc. are not allowed)
Last Name/Surname
First Name
Middle Name
* 7. Address
(R) Residential Address
Name of
Office
Flat/Door/Blo
ck No.
Flat/Door/Blo
ck No.
Name of
Premises/Bui
lding/Village
Name of
Premises/Bui
lding/Village
Road/Street/L
ane/Post
Office
Road/Street/L
ane/Post
Office
Area/Locality/
Taluka/SubDivision
Area/Locality/
Taluka/SubDivision
Town/City/Dis
trict
Town/City/Dis
trict
State/Union
Territory
-- Please select --
State/Union
Territory
Pin (Indicating
PIN is
mandatory)
Pin (Indicating
PIN is
mandatory)
Country
Name
Country
Name
Zip
Zip
Residential
-- Please select --
Office
NSDL.
Tel
Mobile No.
ephone
No.
* 9. Telephone No.
(Country code is compulsory)
Area/STD Code
Telepho
ne
No./Mobi
le No.
E-mail ID
* 10. Status of the Applicant
Individual (P)
Company (C)
Limited Liability Partnership (E)
(b
)
(c)
If you are not covered by (a) or (b) above, indicate sources of income, if any.
14. Full name, address of the Representative Assessee, who is assessable under the
Income Tax Act in respect of the person, whose particulars have been given in column
1 to 13
(Representative Assessee details to be filled only in special cases like minor, lunatic,
idiot, etc., as provided u/s 160 of Income-tax Act, 1961)
Yes
No
-- Please select --
as proof of
identity,
-- Please select --
,the
DD
01 -
MM
03 -
YYYY
2015
Other Details
1. Depository Account Details
DP ID:
Client ID:
2. Payment Details (select appropriate mode of payment and fill relevant details)
for
dated DD
MM
105.00
drawn on
Cheque number
for
105.00)
dated DD
MM
YYYY
105.00
drawn on
Bank,
Branch
at
location (city/town).
105.00)
Submit
Select Ward/Circle/Range/
Commissioner
ITO3(4),LAKHIMPUR- --1
Description
Area AO Range AO
Code Type Code Number
LKN W
43
ITO3(5),LAKHIMPUR- --2
LKN W
43