2 Type of Entity (Choose one)

UN Body

Embassy

Other Person

5

Notification No.

Notification Date

DD/MM/YYYY

6

Address of office of UN Body/ Embassy /any other person in State

Building No./Flat No.

Floor No.

Name of the Premises/Building

Road/Street

Locality/Village

City/District

State

PIN Code

Contact Information

Office Email Address

Office Telephone

STD

number

Mobile Number

Office Fax Number

STD

7

Center Jurisdiction

8

Sector, Circle, Ward, etc. as applicable

9

Authorized Signatory Details

Particulars

First Name

Middle Name

Surname

Name

Name of Father

Date of Birth

DD/MM/YYYY

Gender

<Male, Female,

Other>

Mobile Number

Email address

Telephone No. with STD

Designation /Status

Director Identification

Number (if any)

PAN

Aadhaar Number

Are you a citizen of India?

Yes / No

Passport No. (in case of

foreigners)

Residential Address

Building No/Flat No

Floor No

Name of the

Road/Street

Premises/Building

Locality/Village

City/District

State

PIN Code

10

Bank Account Details of UN Body/ Embassy /any other person

Account Number

Type of Account

IFSC

Bank Name

Branch Address

11

Document Upload

The authorized person who has in possession of the documentary proof (UN Body/ Embassy etc.) must

upload the scanned copy of such documents including the copy of resolution / power of attorney,

authorizing the applicant to represent the UN Body / Embassy etc. in India.

Or

The authorized tax official who has collected the documentary proof from the applicant (UN Body/ Embassy

etc.) must upload the scanned copy of such documents including the copy of resolution / power of attorney,

authorizing the applicant to represent the UN Body / Embassy etc. in India and link it along with the UIN

generated and allotted to respective UN Body/ Embassy etc.

12

Verification

I hereby solemnly affirm and declare that the information given herein above is true and correct to the best

of my knowledge and belief and nothing has been concealed there from.

Place

(Digital Signature/ E-sign)

Date

Name of Authorized Signatory

Or

(Digital Signature of the Proper Officer)

Place

Name of Authorized Proper Officer

Date

Designation