Escolar Documentos
Profissional Documentos
Cultura Documentos
13(1) 26
Application ID :
111695369
/ FORM 6
/
Application for inclusion of name in electoral roll
/ To,
(GEN)
5 -
:I request that my name be included in the electoral roll for the above Constituency. Particulars in support of my claim for
inclusion in the electoral roll are given below :
1.
details
/ Applicant's
1 2016 /
Age as on 1st January 2016
,
( ) :
Name : ASHOK
/ Place of Birth
Father's Name :
II.
2.
: ( )
/ Months :
/ Sex :
Male
(Village/Town) : ABDULPUR
District : UTTARDINAJPUR
( ) :
GALI NO-8
/ / / / :
/
SAMAIPUR
Town / Village :
SAMAIPUR
Post Office :
S-84
SWAROOP NAGAR
02-Jan-1978
37
/ Years :
110042
Pin Code :
SWAROOP NAGAR
: Tehsil /Taluka/Mandal/Thana :
DELHI
District
3. :
III. Details of member(s) of applicant's family already included in the current electoral roll of the Constituency:
1.
/ Name
BHAGWAN SINGH
/
Relationship with
applicant
Brother
2.
Mobile Number : 9540422040
/ Serial Number
of in that part
./
Elector's Photo Identity
Card Number
KSP1490481
....................................................................................................................................................................................
....
Application ID : 111695369
Received the application in Form-6 of Shri/Shrimati/Kumari ASHOK Address S-84, SWAROOP NAGAR, DELHI
Date : 18-Jan-2016
IV. / Declaration
(ii)
(iii)
(, , )
05-Feb-2003
(iv) *
(i)
I am a citizen of India.
(ii)
I am ordinarily resident at the address given in para II above since
(date, month, year)
05-Feb-2003
(iii) I have not applied for the inclusion of my name in the electoral roll for any other constituency :
(iv) * My name has not already been included in the electoral roll for this or any other assembly constituency:
/ Or
* / /
/ /
/ / // / / //
/ / // /
/ / /
/ / //
/ / / /
/ / / / / //
/ /
/ / / / / / / / / / / / / / / /
* My name may have been included in the electoral roll for constituency in state in which I was ordinarily resident earlier at the
/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /
address mentioned below and if so, I requested that the same may be deleted from that electoral roll.
/ / (
/ / / :/
/ / /
/ / /
/ )/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /
Not Applicable
Number :
:
Date :
:
Place :
Not Applicable
. (
18-Jan-2016
Date of Issue :
, 1950(1950
43)
31
Note - 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 (43 of 1950)
/ Details of action taken
( )
(To be filled by Electoral Registration Officer of the constituency)
6 * / *
The application of Shri/Smt./Km. ASHOK for inclusion of name in the electoral roll in Form 6 has been accepted*/recjected*.
Detailed reasons for *acceptance [under or in pursuance of rule 18*/20*/26(4)] or *rejection [under or in pursuance of rule
17*/20*/26(4)]:
Place:
Date:
( , , ) / Remarks of
Field Level Officer (e.g. BLO, Designated Officer, Supervisory Officer.)