ELECTION COMMISSION OF INDIA 6 (See Rule-8B of ...

1 ELECTION COMMISSION OF INDIA / a nj j Miza . FORM-6A/got -6V. (See Rule-8B of Registration of Electors Rules, 1960)/th fhs g f , 1960- 8(B)I fh f). Acknowledgement No/x if v ._____. (To be filled by office/ mYtyf ga gh o fhf). Application for Inclusion of Name in Electoral Roll by an Overseas Elector/. bt ehL th th fhs xUt bgaiu th fhs g oa nr gj fhd z g . PASTE ONE. RECENT PASSPORT. To, The Electoral Registration Officer/th fhs g m fh , .. SIZE. Assembly Constituency/r l nguit bjhF PHOTOGRAPH ( I request that my name may be included in the electoral roll for the Constituency in which my place of residence CM X CM). SHOWING. is located as mentioned in (j) below/ nH (j) F L sthW v Dila t l mik J s FRONTAL VIEW OF. bjhF fhd th fhs g oa vdJ bgaiu nr FkhW nf L bfh nw : FULL FACE WITHIN.

2 (a) Name/ bga * (in Tamil) THIS BOX. Kf KGikahd (j ) K w njh w ij . fh L w,fl L. (in English) ms s ( X br. ) r g a if gl . (M y ). x id f l F . x Ltj fhd l . (b)Last Name/fil bga * (in Tamil). (j ). (in English). (M y ). (c) Name of relative/ Father/j ij Mother/jh Husband/fzt Wife/kid . cw d bga * Other/Vidnah . (in Tamil). (j ). (in English). (M y ). (d)Last Name of relative/cw d fil bga (in Tamil). (j ). (in English). (M y ). (e) Date of Birth (dd/mm/yyyy). w j nj (eh /khj /M L). (f)Place of Birth/ Village/Town w j l uhk /efu . District/kht l . State/kh y . (g) Gender(Put a cross mark in proper box) Male/M Female/bg . gh d (bghU jkhd f l F Lf). Third Gender/ /_ wh gh d . (h) Email id# / d r Kft #. (i) Mobile No.# / if ng v . #. (j)Address in INDIA as mentioned in original passport / mr House No/.

3 Fl o F L sthW a Kft o v . Street/Area/Locality bjU/gF /t lhu . Town/Village efu / uhk : District Pin Code kht l m r F p L v : (k)Details of current Passport/ Place of Issue/. j nghija fl o tu f tH f g l l . Passport No. Date of expiry fl L v . (dd/mm/yyyy). fhyht ahF . eh (eh/kh/M). Date of issue(dd/mm/yyyy). tH f g l eh (eh/kh/M). (l) Details of Visa of the Country of current residence/ Visa Number/. j nghJ t w eh o EiH ir tu f EiH ir . v . Date of issue/ Date of expiry/. tH f g l eh fhyht ahF . eh . Type of Visa/ Name of issuing Authority/ tH F . EiH ir m fh bga . tif * To be filled in capital letters only / bg a vG J f dh k Lnk u g gl nt L . # Optional / U ik Note:- Copies of the relevant pages of the passport containing the particulars mentioned at items (a) to (l) and current valid visa endorsement mentioned above to be enclosed - duly self attested if sent by post and produced with the original passport if presented in person before the registration officer/ m r _y mD g gL ne , nkny (a) Kj (i) tiu yhd d f F l g L s tu f ml a fl o bjhl ila g f f ef f , j fthW Ra rh bwh g l g L, iz f glnt L.

4 G m fh K iy . neuoahf m f g lh , _y fl L fh f glnt L . 2. (a) Reason of being absent from the place of Employment/ Education/ Other(give Description). ordinary residence in INDIA /, ah ntiy th f Vidait ( tu jUf). iyahd t l t fhik fhd fhuz . (b) Date from which absenting from ordinary residence in INDIA (dd/mm/yyyy). ah iyahd t l v j eh U J t f iy (eh/kh/M). 3. Full current Address in the country outside INDIA where residing- House No. ah F bt na j nghJ t J tU w eh oY s KG t l o v . Kft . Street/Area/Locality bjU/gF /t lhu . Town/Village /efu / uhk : State / kh y Country/. ehL. Zip code/ m r F p L v : DECLARATION . I hereby declare that to the best of knowledge and belief cW bkh - vd F e whf bj j tiu Y , eh e w tif Y . a. All information given in this application is true / j z g m J s mid J jft fS.

5 C ikahdit. b. I am a citizen of INDIA by birth/domicile/naturalisation / eh , w gh / ciw l jh / Fo ika f g ljdh , X a Fokf . c. I have not acquired citizenship of any other country / eh , ntbw j eh o Fo ikia bgw iy. d. But for being absent from the place of my ordinary residence in INDIA owing to the reason given in 2 (a) above, I would have been ordinarily resident at the address given in my Indian Passport which has been reproduced at 1 (g) above/. ah v Dila rhjhuz t l eh t fhik fhf nkny 2(a)- m f g l fhuz . yhk ngh U jh , nkny 1(j)- Y , v Dila a fl oY F l g L sJkhd Kft , eh rhjhuz Fo U ghsuhf t J t U ng . e. I undertake to immediately inform the Electoral Registration Officer through the Indian Mission in the Country of my current residence if I renounce my Indian Citizenship or if I acquire the citizenship of any other country.

6 / eh . v Dila a Fo ik id Jw jhnyh, eh ntbwhU eh o Fo ik bg whnyh, eh t F . eh oY s a juf th yhf, th fhs g m fh l cldoahf bj gjhf cW a nw . f. I undertake to immediately inform the Electoral Registration Officer through the Indian Mission in the country of my current residence of any change in my residential address in the country of my residence for the records of the Electoral Registration Officer. I understand that any notice sent to me at the address, which is my residential address in the country of my current residence according to the records of the Electoral Registration Officer, shall be considered as due service of notice to me under the Representation of the People Act, 1950 and the rules made thereunder, and that it is my responsibility to keep the Electoral Registration Officer informed of my latest residential address in the country of my current residence.

7 / j nghJ eh t w eh o v Dila t l Kft . VnjD kh w U , v Dila j nghija t l g , eh oY s a juf th yhf, th fhs g m fh g U f g br Jbfh tj fhf th fhs g m fh F cldoahf bj gjhf eh cW a nw . th fhs g m fh g U f c sthW, j nghJ eh . t w eh oY s v Dila t l Kft F mD g g l ahbjhU m , 1950-M M L. k f u Jt r l k W mj a w g l f vd F c athW tH f g l m ghf fUj gL v W eh m nt . j nghJ eh t w eh oY s v Dila m ik fhy t l Kft F J, th fhs g m fh F bj gJ v Dila bghW ghF . g. If I return to INDIA and become ordinarily resident in INDIA , I shall immediately inform the Electoral Registration Officer of the concerned Assembly/Parliamentary Constituency. / eh ah F U t J, ah rhjhuz Fo U ghsuhf t F nghJ, r g j g l r lk w bjhF / ehlhSk w bjhF th fhs . g m fh F cldoahf jft bj ng . h. I have not applied for inclusion of my name in the electoral roll of any other Constituency / Vida ahbjhU.

8 BjhF th fhs g oa Y v Dila bgaiu nr gj F eh z f iy. i. My name has not already been included in this or any other Constituency / j bjhF nyh, Vida ahbjhU. bjhF nyh v Dila bga V bfdnt nr f gl iy. Or / m yJ. My name may have been included in the Electoral Roll of .. Constituency in .. State in which I was ordinarily resident earlier at the address mentioned below and, if so, I request that the same may be deleted from that electoral roll or transposed, as may be appropriate..kh y , nH F l g l Kft , eh , K d rhjhuz Fo U ghsuhf U jnghJ, ..bjhF th fhs g oa vdJ bga nr f g oU fyh . v W m thW nr f g oU , m j th fhs g oa U J bga f m yJ l kh w . ( u o vJ bghU jnkh mij ) br ayh v W eh nf L bfh nw . Full address (Earlier place of ordinary residence) .. KG Kft (K ija rhjhuz t l gF ).

9 Electors Photo Identity Card (if issued) number th fhs if gl milahs m il (tH f g oU ) v .. Date of issue / tH f g l eh .. j. I have not been issued an EPIC in INDIA /have been issued an EPIC which is enclosed with this application for vd F, ah , th fhs if gl milahs m il tH f gl iy / th fhs if gl milahs m il tH f g L sJ. J, u Jbr a gLtj fhf, j z g Jl iz f gL wJ. 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). F : vtuhtJ bgh ahd m yJ bgh ahdbj W jh m J s m yJ e w m yJ c ikahdbj W e ghj m ifia m yJ cW bkh ia bfhL jh mt 1950M M o k f u Jt r l (1950 43). 31tJ j o f gl j ftuhth . Signature / ifbah g.

10 Place / l .. Date / eh .. Details of action taken (To be filled by Electoral Registration Officer of the constituency). nk elto if vL f g l tu f (bjhF th fhs g m fh ah br a gl nt oaJ). Application received on/ z g bgw g l eh ..(DD/MM/YYYY eh /khj /M L). The application in Form 6A of Thiru/Tmt/Selvi ..has been :- (a) Accepted and the name has been registered in the electoral roll of ..(constituency). at ..Part No .. U/ Uk /br .. got 6V z g bgw g L. (m) V f g L ..(bjhF ) th fhs g oa ghf v .. t ir v . nr f g L sJ. (b) Rejected for the reason/ ..fhuz fhf uhf f g lJ:- 0. Date/eh :_____ Name/Signature of ERO/AERO. / .m bga / ifbah g . Acknowledgement/Receipt x if / u J. Acknowledgement Number x if L v _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date/eh _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.