Here is a sample Gazetted form format for Pan card application

TO WHOM SO EVER IT MAY CONCERN

This is to certify that _________________________________________
__________________________________________________________
Born on (____/____/______) D/o or S/o _________________________
is residing at _______________________________________________
__________________________________________________________
__________________________________________________________
This Certificate is issued for the purpose of applying PAN CARD

NOTE: GOVERNMENT GAZETTED OFFICER ONLY NOT NOTARY PUBLIC OFFICER