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,-
I.
Applicants
details
.a!e () Surna!e (if an#) { ()}
( /loc0
'a+ital
1etters )

ge as on 1
st
2anuar# 333.. 4 5ears- 6onths-
Se7(!ale$fe!ale)-
Date of birth, if known 8a#- 6onth- 5ear-
!lace of birth - 9illage$To,n -
8istrict - State -
: ;ather<s$
6other<s $ .a!e
=us"and<s
.a!e () Surna!e (if an#) { ()}
(/loc0
'a+ital
1etters)

II. !articulars of place of present ordinar" residence #Full address$ (

)
=ouse% 8oor .o. ( )
Street$rea$1ocalit#$6ohalla$Road (///)
To,n $ 9illage ( /) -
%ost Office ( ) - %in 'ode ( )
Tehsil$Talu0a$6andal$Thana () -
8istrict () -
III. Details of member#s$ of applicants famil" alread" included in the current electoral roll of the
constituenc"
.a!e Relationshi+ ,ith
a++lication
%art nu!"er of
the roll of the
'onstituenc#
Serial nu!"er in
the +art
Elector<s %hoto (dentit#
'ard .u!"er
1.
2.
& (n case of >nion territories ha*ing no 1egislati*e sse!"l# and the State of 2a!!u ? @as!ir
4 %lease gi*e the #ear i.e. 2A12, 2A13 etc.
: Stri0e out the ina++ro+riate alternati*e.
&!A'( FOR !A&)I*+
O*( R('(*)
!A&&!OR) &I,(
!-O)O+RA!- #../
'M 0 ../ 'M$
&-O1I*+
FRO*)A2 3I(1 OF
F422 FA'( 1I)-I*
)-I& 5O0
&i6nature or thumb impression of the applicant
I3. Declaration
( here"# declare that to the "est of !# 0no,ledge and "elief-B
(i) ( a! a citiCen of (ndiaD
(ii) ( a! ordinaril# resident at the address gi*en in +ara (( a"o*e since 3333333.(date,
!onth, #ear)D
(iii) ( ha*e not a++lied for the inclusion of !# na!e in the electoral roll for an# other constituenc#D
(i*) :6# na!e has not alread# "een included in the electoral roll for this or an# other asse!"l#
constituenc#D
or
:6# na!e !a# ha*e "een included in the electoral roll for333333333 'onstituenc#
in 33333333333.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 address (Earlier +lace of ordinar# residence)-
EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE
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EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE
EEEEEEEEEEEEEEEEEEEEEEEEEEE
Electors +hoto identit# card (if alread#
issued) EEEEEEEEEEEEEEEEE

8ate of issue EEEEEEEEEEEEEEEEEEE
%lace -
8ate -
c$ *ote An" person who makes a statement or declaration which is false and which he either knows or belie7es to be
false or does not belie7e to be true, is punishable under section .8 of the Representation of the !eople Act, 89/: #;.
of 89/:$.
: Stri0e out the ina++ro+riate alternati*e.
The a++lication of
Shri$S!t.$@!. 3333333333333333333333333..................33for inclusion of
na!e in the electoral roll in ;or! 6 has "een acce+ted : %reFected :.
8etailed reasons for : acce+tance [under or in +ursuance of rule 1G:$2A:$26(H)]
&
or :reFection [under or in
+ursuance of rule 1I:$2A:$26(H)
&
]

-
%lace -
8ate -
Signature of Electoral
Registration officer
(Seal of the Electoral
Registration Officer)
&
8uring continuous u+dating after final +u"lication of electoral roll.
: Stri0e out the ina++ro+riate alternati*e.
Remarks of Field 2e7el Officers #e.6. 52O, Desi6nated Officer, &uper7isor" Officer$
[;OR6 6 'ontd3..]
Details of action taken
#)o be filled b" (lectoral Re6istration Officer of the constituenc"$
<)his pa6e should be thick enou6h so that it does not 6et mutilated % dama6ed in postal transit=
3333333333333333333 ;irst ;old 33333333333..333333
SectionB(
The a++lication in ;or!B6 of
:: Shri$Shri!ati$@u!ari33333..
::(;ull ddress)
=ouse$8oor nu!"er-
Street$rea$1ocalit#$
6ohalla$Road-
To,n$9illage-
%ost Office- %in 'ode-
Tehsil$Talu0a$
6andal$Thana-
8istrict-
:: To "e filled in "# the a++licant.
333333333333333333 Second ;old 3333333333..333333. .
SectionB((
has "een33
(a) acce+ted and the na!e of Shri$ Shri!ati$@u!ari33333333.33333333 has "een
registered at Serial .o. 3333. in %art .o. 3333.. of ' .o. ? .a!e
333333333..
(") reFected for the reason 33..333333333333333333333333333...
8ate33333333.
Electoral Registration Officer
(ddress) 33333333
333333333333.
333333333333.
333333333333333 %erforation for detach!ent 3333333333..333
Receipt for application
Recei*ed the a++lication in ;or! 6 of :: Shri$Shri!ati$@u!ari33333333333333..
::ddress3333333333333333333333333333333333.3
8ate33333 Signature of the officer recei*ing the a++lication
on "ehalf of the Electoral Registration Officer
(ddress) 333333333333..33.
:: To "e filled in "# the a++licant.
Intimation of action taken
#&ection>II of the pa6e is to be filled in b" (lectoral Re6istration Officer of the constituenc" and to be
posted to the applicant on the address as 6i7en b" the applicant in &ection>I$
%ostage Sta!+ to "e
affi7ed "# the
Electoral
Registration
uthorit# at the
ti!e of dis+atch