FORM 6 Application for inclusion of name in electoral roll

1 form 6[See rules 13(1) and 26] Application for inclusion of name in electoral rollToThe electoral Registration Parliamentary ,I request that my name be included in the electoral roll for the aboveConstituency. Particulars in support of my claim for inclusion in the electoralroll are given below:I. Applicant sdetailsNameSurname (if any)Age as on 1stJanuary ..#Years:Months:Sex (male/female/others):Date of birth, if known:Day:Month:Year:Place ofbirth:Village/ Town:District:State:* Father s/Mother s/ NameHusband sNameSurname (if any)II. Particulars of place of present ordinary Residence (Full address)House/ Door number:Street/ Area/Locality/Mohalla/Road:Town/ Village:Post Office:Pin Code:Tehsil/ Taluka/Mandal/ Thana: of member(s) of applicant s family already included in the current electoral roll of theConstituency:NameRelationshipwith applicantPart number of theroll of theConstituencySerial numberin that PartElector s PhotoIdentity In case of Union territories having no Legislative Assembly and the State of Jammu & Kashmir.

2 # Please givethe year 2007, 2008, etc.* Strike out the inappropriate alternativeSPACE FOR PASTINGONE RECENTPASSPORT SIZEPHOTOGRAPH( CM X CM)SHOWING FRONTALVIEW OF FULL FACEWITHIN THIS BOXIV. DeclarationI hereby declare that to the best of my knowledge and belief:-(i)I am a citizen of India;(ii)I am ordinarily resident at the address given in para II abovesince ..(date,month, year)(iii)I have not applied for the inclusion of my name in the electoral roll for any otherconstituency;(iv)*My name has not already been included in the electoral roll for this or any otherassembly constituency;Or*My name may havebeen included in the electoral roll for_____Constituency in _____State in which I was ordinarilyresident earlier at the address mentioned below and if so, I request that thesame may be deleted from that electoral Address (Earlier Place of ordinary residence)_____Electors Photo Identity Card number (ifalready issued)_____Date of issue _____Place:Date: Signature or thumb impression of the applicantPlease give your mobile number/E-mail (Optional)/.

3 A)Note Any person who makes a statement or declaration which is false and which he eitherknows or believes to be false or does not believe to be true, is punishable under Section 31 of theRepresentation of the People Act, 1950 (43 of 1950).* Strike out the inappropriate of action taken(To be filled by electoral Registration Officer of the constituency)The Application inclusionofname in the electoral roll in form 6 has been accepted*/rejected*.Detailed reasons for *acceptance [under or in pursuance of rule 18*/20*/26(4)] or* rejection [underor in pursuance of rule 17/20*/26(4) ]:Place:DateSignature of ElectoralRegistration Officer(Seal of the ElectoralRegistration Officer) During continuous updating after final publication of electoral roll.

4 * Strike out the inappropriate of Field Level Officers ( BLO, Designated Officer, Supervisory Officer)[ form 6 ][This page should bethick enough so that it does not get mutilated /damaged in postal transit]Intimationof action taken(Section-IIof the page is tobe filled by electoral Registration Officer of the constituency and tobeposted to the applicant on the address as given by the applicantin Section-I)------------------------------ ----------------------------------First Fold------------------------------------ ---------------------------------------- ---------------------------------Section -IPostage Stamp to beaffixed by theElectoral RegistrationAuthority at the timeof dispatchThe Application in form 6 of**Shri/ Shrimati/ **(Full address)House/ Door number:Street/ Area/Locality/Mohalla/Road:Town/ Village:Post Office:Pin Code:Tehsil/ Taluka/Mandal/ Thana:District:** To be filled in by the Fold------------------------------------ --Section-IIhas been (a) accepted and the name of Shri/ been registered at Serial AC No.

5 (b) rejected for the electoral Registration Officer.(Address)..Perforation for for applicationReceived the Application in form 6 of ** Shri/ ** of the officer receiving the applicationon behalfof the electoral Registration Officer(Address) ..** To be filled in by the , ,theapplicationcanbefiledatthedesignated locationswherethedraftelectoralrollisdis played(mostlypollingstationlocations) , (WithDocumentaryProof)Thenameasitshoulda ppearintheelectoralrollandElectorsPhotoI dentityCard(EPIC) , , ,Khan,Begum, (WithDocumentaryProof) p p l i c a n t s m a y i n d i c a t e t h e i r s e xa s o t h e r w h e r e t h e y d o n o t w a n t t o b e d e s c r i b e d a s m a l e o r f e m a l e.

6 (WithDocumentaryProof)Fillupthedateofbir thinfiguresinthespaceprovidedindd/ :i)BirthcertificateissuedbyaMunicipalAut horitiesordistrictofficeoftheRegistrarof Births&DeathsorBaptismcertificate;orii)B irthcertificatefromtheschool( )lastattendedbytheapplicantoranyotherrec ognisededucationalinstitution;oriii)Ifap ersonisclass10ormorepass,heshouldgiveaco pyofthemarksheetofclass10,ifitcontainsda teofbirthasaproofofdateofbirth;oriv)Mark sheetofclass8ifitcontainsdateofbirth;orv )Marksheet of class 5 if it contains date of birth; orvi)A declaration in prescribed format given in Annexure-1 made by either of his parents if the person is noteducated till class 10 (In those cases where parental declaration is given as proof of age, the applicant willhave to be present himself for verification before BLO/ERO/AERO); orvii)A certificate of his age given by a sarpanch of the concerned Gram Panchayat or by a member of theconcerned Municipal Corporation / Municipal Committee, the person is not educated till class 10 and both theparents are not : Documentary proof of age will be required only in those cases, where age of the applicant is between18 and 21 years.

7 In all other cases declaration of his age by the applicant will be taken as proof of of BirthIn case born in India, please mention name of place like Village / Town, District, s name :In case of unmarried female applicant, name of Father / Mother is to be mentioned. In case of married femaleapplicant, name of Husband is to be mentioned. Strike out the inapplicable options in the of Ordinary ResidenceFill up the full and complete postal address including PIN code where you are ordinarily residing and want to getregistered, in the space of ordinary residence to be attached are as under:i)Bank / Kisan / Post Office current Pass Book, orii)Applicant s Ration Card / Passport / Driving License / Income Tax Return filed or Assessment Order, oriii)Latest Water / Telephone / Electricity / Gas Connection Bill for that address, either in the name of theapplicant or that of his / her immediate relationlike parents etc.

8 , oriv)Postal department s posts received / delivered in the applicant s name at the given : In case of homeless persons, the BLO will visit the address given in form 6 at night to ascertainthat the homeless person actually sleeps at the place which is given as his address in form 6. If the BLO isable to verify that the homeless person actually sleeps at that place, no documentary proof of place ofresidence shall be must visit for more than one night for of Family Members Already Included in the electoral RollPlease fill up name and other particulars of immediate family members Father / Mother / Brother / Sister / Spouseincluded in the current electoral roll of the constituency.

9 name of any other relation like uncle, aunt, cousin brother / sistersetc. not to be indicate date from which you are residing in the given address. In case the exact date is not known, fill-upmonth and your name is already included in the electoral roll of any other constituency, please write legibly the fullprevious address with PIN you already have been issued with a Photo Identity Card by the Election Commission, please mention the cardnumber (printed on the front side) and date of issue (printed on the back side) of the card in the space provided. Pleaseattach a self-attested photocopy of both sides of the many places the photograph of the elector is also printed in theelectoral roll.

10 You have the option to submit one recentcoloured passport-size photograph alongwith the form . The photograph will be used to print your image in the electoral rolland issue of identity card, if also give your full name and address on the acknowledgement and intimation give your mobile number and E-mail in the form , which is optional, asthe same ,ifgiven,may be used by theElectoral Registration Officer for further communication with the applicant whenever required.