FORM 6

[See rules 13(1) and 26]

Application for inclusion of name in electoral roll

To The Electoral Registration Officer, & ... sse!"l#$%arlia!entar# 'onstituenc# Sir, ( re)uest that !# na!e "e included in the electoral roll for the a"o*e 'onstituenc#. %articulars in su++ort of !# clai! for inclusion in the electoral roll are gi*en "elo,.a!e Surna!e (if an#)

I. Applicants details
ge as on 1 /anuar#0..1 5ate of 6irth, if 7no,n %lace of 6irthst

2ears5a#8illage$To,n5istrict .a!e

3onths3onth-

Se4 (!ale$fe!ale)2earStateSurna!e (if an#)

9 :athers
3others ;us"ands .a!e

II.

Particulars of place of ordinary residence (Full address):

;ouse$5oor nu!"erStreet$ rea$<ocalit#$3ohalla$RoadTo,n$8illage%ost OfficeTehsil$Talu7a$3andal$Thana5istrict

%in 'ode

In case of Union erritories !a"in# no $e#islati"e Assem%ly and t!e &tate of 'ammu and (as!mir. ) Please #i"e t!e year i.e. *++,- *++. etc. / &tri0e out t!e inappropriate alternati"e.

11..11111111111111111..(Perforation)11111111111111111111111111

Receipt for application

Recei*ed the a++lication in :ro! 6 of 99 Shri$Shri!ati$=u!ari0000000000000000000.. 99 ddress000000000000000000000000000000000000000000

5ate-0000.

Signature of the officer recei*ing the a++lication on "ehalf of the Electoral Registration Officer ( ddress)000000000000000 000000000000000

// o %e filled in %y t!e applicant.

III. 3etails of mem%er(s) of applicant6s family already included in t!e current electoral roll of t!e 7onstituency:
.a!e Relationshi+ ,ith a++licant %art nu!"er of the roll of the 'onstituenc# Serial nu!"er in that %art Electors %hoto (dentit# 'ard .u!"er

1. 2.

I2. 3eclaration:
( here"# declare that to the "est of !# 7no,ledge and "elief-> (i) ( a! a citi?en of (ndia@ (ii) ( a! ordinaril# resident at the address gi*en in +ara (( a"o*e since .. (data, !onth, #ear)@ (iii) ( ha*e not a++lied for the inclusion of !# na!e in the electoral roll for an# other constituenc# @ (i*) 9 3# na!e has not alread# "een included in the electoral roll for this or an# other asse!"l# constituenc#@

Or
9 3# na!e !a# ha*e "een included in the electoral roll for .
'onstituenc# in . State in ,hich ( ,as ordinaril# resident earlier at the address !entioned "elo, and, if so, ( re)uest that the sa!e !a# "e deleted fro! that electoral roll. :ull ddress (Earlier +lace of ordinar# residence)Electors +hoto identit# card (if issued) 000- date of issue. nu!"er-

%lace-

5ate-

&i#nature or t!um% impression of t!e claimant

4ote> Any person who makes a statement or declaration which is false and which he either knows or believes
to be false or does not believe to be true, is punishable under section 31 of the Representation of the People Act, 1950 !3 of 1950"#

/ Stri7e out the ina++ro+riate alternati*e.

3etails of action ta0en ( o %e filled %y 5lectoral Re#istration Officer of t!e constituency)

The a++lication of Shri$S!t.$=! inclusion of na!e in the electoral roll in :or! 6 has "een acce+ted9$reAected9. 5etailed reasons for 9 acce+tance [under or in +ursuance of rule 1B 9$2C9$ 26(D)] 9reAection [under or in +ursuance of rule 1E9$2C9$ 26(D)& ]&

for

or

%lace5ate

Signature of Electoral Registration Officer

(Seal of the Electoral Registration Officer)

3urin# continuous updatin# after final pu%lication of electoral roll.

/ &tri0e out t!e inappropriate alternati"e.