FORM – 6

[SEE RULES 13(1) AND 26]

APPLICATION FOR INCLUSION OF NAME IN ELECTORAL ROLL

To The Electoral Registration Officer, ……………………………..Assembly/Parliamentary Constituency. Sir, 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. Applicant’s details

1. Title

2. First and middle name

3. Last name

4. Age on 1^st January……

5. Years:

6. Months:

7. Sex(male/female):

Date of birth, if known:

8. Day:

9. Month:

10. Year:

Place of birth:

11. Village/Town:

12. District:

13. State:

11. (a) Details of relation of applicant (father/ Mother/Husband)

14. Title

15. First & middle name:

16. Last name

(b) Relationship with applicant . Father/Mother/Husband:

III. Particulars of place of ordinary residence (Full address):

17. House/Door number:

18. Street/Mohalla/Road/Gali:

19. Area/Locality:

20. Town/Village:

21. Post Office:

22. Pin Code:

23. Police Station:

24. Tehsil/Taluka:

25. Block/Mandal(for village)

26. District:

IV. Period of continuous residence at the above mentioned address on the date of application.

27. Years:

28. Months:

V. Details of local Body and Ward in which the place of ordinary residence al III above is included:

29.a)Notified Area Committee/Municipality/Municipal Corporation/cantonment Board 9(for urban area)

b. Gram Panchayet (for rural area)

30. Ward number of the above local Body:

VI. Reference in support of claim, if any [ Details of member(s) of applicant’s family included in the current electoral roll of the constituency:

Name (s)

Relationship with applicant

Part number of the roll of the Constituency

Serial number in the part

1

2

3

VII. Details of Elector’s Photo Identity Card, if issued, in this or any other Constituency

31. Elector’s Photo identity Card number:

32. Date of issue:

33. Constituency (Assembly/Parliamentary Constituency) Name:

VIII. Declaration I hereby declare that – (I) I am a cititzen of India (ii) I have not applied for the inclusion of my name in the electoral roll for any other Constituency; (iii) (a) My name has not been previously included in the electoral roll for this or in any other Assembly/ parliamentary Constituency; or (b) I was an ordinary resident earlier at the address mentioned below an my name is included/might have been included in the relevant part of the electoral roll for:

34. Assembly/Parliamentary Constituency

Number:

Name:

35. State/Union territory:

36. Part number:

37. Serial No.

38. House/Door number:

39. Street/Mohalla/Road/Gali:

40. Area/Locality:

41. Town/Village:

42. Post Office:

43. Pin Code:

44. Police Station:

45. Tehasil/Taluka:

46. Block/Mandal

47. District:

I request that my name, so included/if so included may be deleted from that electoral roll. (iv) . The facts & particulars mentioned above are true to the best of my knowledge and belief. Place: Date: Signature or thumb impression of claimant

I am submitting the application to the Electoral Registration Officer through (i) Shri/Smt/Km. (full name & address) or (ii) in person / or (iii) by post … ……………………………………………. Signature or thumb impression of claimant

Note - Any person who makes a statement of 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

Signature of thumb impression of the

Person submitting the application