WWW.SARKARIDOCTOR.COM

WWW.SARKARIDOCTOR.COM
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Annexure Sl
Annli.utioo fo. AIIot*.nt of
P.r*rr.nt R.tir.rn.rt A..ornt Nr*bir
(pRAN)
(To avoid mistake(s), please follow the accompanying rnstructions and examples caretully beiore filling
up rhe fbrm)
Acknowledgemenl No.
(To be filled by FC)
Permanent Retirement Account Number
(To be filled by FC after PRAN generation )
:
5ffi
SirMadam,
I hereby request that a permanent retirement account number be ailotted to me
I give below necessary particulars
:
Section A - Subscribers Personal Details ( * Inclicates Mandator
y-
Srgnature,4-eft Thumb Lrpres: i.r'
ol Subscriber in black ink
Field)
Full Name lFull expande'd name: initials are nor permiued)
PleaseTick
First Name *
asapplicable, Shri
[|
S;
-' tr
Kuma.
I
Middle Name
2. Gender
+
3. Date of
Birth *
Please
Tick
as
applicable, vae El-
4
ffi4PAN
D D M M Y Y Y Y
Father's Full Name
First Name {
tr
Female
PAN
(DateofBrrthrobeCenifiedbyDDO)
6. Present Address
Flat/Unit No. Block no *
Pin Code *
7. Permanent
l:gfol_Tl-oTt-I3l
Address: Ifsame
FlaL{Jnit No. Block no.
as above, please Tick
+
Premise/Bui
Pin Code
+
8. Phone No.
t31il2-r-il1-trl
El]<Tzrar
S'fD Code
9. Mobile No.
rfl-9TrTilffi
Phone No
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Subscribers Bank Details
Bank A,/c Number
Please refer instructron no.
f(4)
Elt
suring.,+,,.
cur.nt e.,.
I-l
Bank Name
Bank Branch
Bank Address
[3To rrl_o rc-fTl
Pin Code
Bank MICR
Code .
12. Value Added Services:
r
i) SMS Aierr
Yes
ii) Email Alen
Yes
V
W
Ar( Sq C\ K Lq
A
5 ETGN o R
KJro
*r,u.tl:cappllica11,..lojicrtbrJ<c|rrct|lrt
iL-
^.-..,
(Wherever applicable)
tr
r
No
No
j
Sry
-.
WWW.SARKARIDOCTOR.COM
Date
:
D D M M Y Y YT
S
Section B - Subscribe.t
L Date of Joining
2-
2
2
i
gnature/Left Tlrr nrlssion ofSubscr ri:cr
r
rm-=u
Date of Retiternent
DDMMYY\
J PPAN
I
4 Group ofthe Employee (please
fick)
c.o,pe
l-l
GroupB
Plr.,se retcr :rr ll\tfu!t,i)tr.
\,, i
)
ffi,.unc' flc;,uupD I
];
5
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:
t'
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8. DDO Registration Number
9
Dl'O Rcersrration Nunrlrcr
(Please reler to instructions No.6.)
F-lo*l-i-l-r T1,?=c
Basic Salary
certified that the above declararion has been signed
/ thunrb inrpressed befbre nre
after he / she has read the entries / entries haveiee
ve been read over to h inr i her by me
details is as
Signature ofthe Authorised person
Designation of the Authorised pcrson
2_
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[r' J r-T e N Q R A
lixionti_rea try ii* I t,.r.
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Name of tlre DDO
f.{eP 9r-o.r-- ftru
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Annexure SI
Section C - Subscriber's Nomination Details (*
l.
Indicares Mandaton,Fielcl krr nunrrnecl
Name of the Nominee *:
1st Nominee
2nd Nominee
Jrd Nominee
First Narne *
Mrdrilt Narre
["ast Name
2. Date of Birth
ln case
of a minor
wrth the Nominee*
I iil
lrcl Norrrinee
5. Nominee's Guardran Details (in case of a minor)*
's Guardian Details
2nd Nominee's Guardian Details
3rd Nomrnee's Guardran Details
First Name *
Micldle Nanre
- --i
,-,
f-l
L_l
Last Nenre
T-
Section D - Subscriber Scheme Details
lst
Scheme
2nd Scheme
Pension Fund Managers Name,iCode
3r d Schcme
Pensiorr Fund Managers Narre/Code
Scheme ID No A.iarrre
Scherne lD No /Nurnc
Perce
e Share
WWW.SARKARIDOCTOR.COM
Section E - Declaration
I understand that there would be PFRDA approved Terms und Conditions lor Subscribers on the CRA wcbsite governitr,g iPin (to access CRA / NPSCAN and view details) & T-pin.I agree to be bound by the said ternrs and condiriops and understarrr.l
that CRA may, as approved by PFRDA, amend any of the services cornpletely or .par.rially without any ne\\
Declaration/[Jndertaking being signed.
I SETCNA RA
KOTN
ArK F&q RS-A
what is stated above is true to the best ofrny infonnation
tlte alrplrr:rrrt rlo hcrchr ilccllrrc thlt
& belief
Date: ffi
DDMMYYYY
Sr
gnalurel l-e ti'l hrLrrrlr
Irloressron tti Suhscrrbr

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