Hkkjr fuokZpu vk;ksx - Uttarakhand

1 Hkkjr fuokZpu vk;ksx ELECTION COMMISSION OF INDIA. QkeZ&6 (FORM-6). [fuokZpd jftLV fu;e 1960 dk fu;e 13 1 vkSj 26 nsf[k,]. (See Rules 13(1) and 26) of Registration of Electors Rule-1960. vfHkLohd`fr la[;k------------------------ Acknowledgement dk;kZy; n~okjk Hkjk tk,xk (To be filled by office). igyh ckj ernkrk ;k fdlh ,d fuokZpu &{ks= ls fdlh vU; ,d fuokZpu &{ks= esa ds fuokZpd ukekoyh esa uke dks lfEefyr djus ds fy, vkosnu Application for Inclusion of Name in Electoral Roll for First time Voter OR on Shifting from One Constituency to Another Constituency. lsok esa] iwjs psgjs dks lkeus ls minf'kZr djrs gq, uohure QksVks ( fuokZpd jftLV vkfQlj] CM X CM) fpidkus ds.}}

2 LHkk fuokZpu {ks=@ lalnh; fuokZpu {ks=A fy, LFkku SPACE FOR. PASTING ONE RECENT. To, PASSPORT SIZE. The Electoral Registration Officer, PHOTOGRAPH ( CM X. CM) SHOWING..Assembly / Parliamentary Consitituency FRONTAL VIEW OF FULL. FACE WITHIN THIS BOX. eS vuqjks/k djrk gwa fd esjs uke dks iwoksZDr lHkh {ks= ds fy, fuokZpd ukekoyh esa lfEefyr fd;k tk;A leqfpr ckWDl ij lgh dk fu'kku yxk;sa . I request that my name be included in the electoral roll for the above Constituency. (Tick appropriate box). igyh ckj ds ernkrk ds :i esa ;k vU; lHkk {ks= ls ds fuokZpd ukekoyh esa lfEefyr fd, tkus ds fy, esjs nkos ds leFkZu esa fof'kf"V;ka uhps nh xbZ gSa&. sa As a first time voter or due to shifting from another constituency Particulars in support of my claim for inclusion in the electoral roll are given below:- vfuok;Z fof'kf"V;ka Mandatory Particulars d uke vkosnd rFkk lEcU/kh (a) Name (InCapital Letter) dk uke fgUnh ,oa vaxzsth esa vfuok;Z :i [k miuke ;fn dksbZ gks.]}}}}

3 Ls fy[kk tk;A vaxzsth (b) Surname(if any) esa dSfiVy ysVj esa x vkosnd ds ukrsnkj dk uke vkSj miuke fy[kuk Hkh vfuok;Z gSA. ns[ksa en ?k . (c) Name and surname of Relative of Applicant [see item (d)]. ?k ukrsnkjh dh fdLe leqfpr ckDl ij lgh dk firk ekrk ifr iRuh vU;. fu'kku yxk;s a Father Mother Husband Wife Other (d) Type of Relation (Tick appropriate box). M- vk;q pkyw dSyaM. s j o"kZ dh 1 tuojh]-------------------- o"kZ ekl ------------dks Years Months (e) Age [as on 1st January of current calendar year ..]. p tUe dh rkjh[k fnu@ekl@o"kZ ds izk:i es a sa ;fn Kkr gks / / /. (f) Date of Birth (in DD/MM/YYYY format)(if known). N vkosnd dk fyax leqfpr ckDl esa lgh dk fu'kku yxk,a iq:"k L=h r`rh; fyax (g) Gender of Applicant (Tick appropriate box) Male Female Third Gender t orZeku irk] ftldk vkosnd ekewyh rkSj ij x`g la0 House fuoklh gS No.]]

4 (h)Current address where applicant is ordinarily resident xyh@{ks=@LFkku Street/Area/Locality 'kgj@xzke Town/Village Mkd ?kj Post Office fiu dksM. Pin Code ftyk jkT;@la?k jkT; {ks=. District State/UT(i). i vkosnd dk LFkkbZ irk x`g la0. (i) Permanent address of applicant House No. xyh@{ks=@LFkku Street/Area/Locality 'kgj@xzke Town/ Village Mkd ?kj fiudksM. Post Office Pin Code ftyk District jkT;@la?k jkT; {ks= State/UT. bZihvkbZlh la- ;fn tkjh fd;k x;k gS . (j)EPIC No. (if issued). oSdfYid fof'kf"V;ka Optional Particulars V fu%'kDrrk ;fn dksbZ gks leqfpr ckDl ij n`'; nqcZyrk okd ,oa lquus dh fu%'kDrrk xfr fo"k;d fu%'kDrrk vU;. (k) Disability (if any) (Tick appropriate box).}}}}

5 Visual impairment Speech & hearing disability Locomotor disability B bZ&esy oSdfYid Other (l) Email id (optional). M eksckbZy la[;k oSdfYid . (m) Mobile No. (optional). ?kks" %. eSa ?kks" djrk gwa fd vius loksZ ke Kku vkSj fo'okl ds vuqlkj %. i eSa Hkkjr dk ukxfjd gwa vkSj esjs tUe dk xzke@'kgj ---------------------------------------- ------- ftyk-------------------------- ------------ jkT; -------------------------------- gSA. ii eSa --------------------------------ls rkjh[k] ekl] o"kZ ij t esa fn, x, irs okys LFkku esa ----------------------------------- ----- ls ekewyh rkSj ls fuoklh gw (. iii eSaus fdlh vU; fuokZpu &{ks= ds fy, fuokZPkd ukekoyh esa viuk uke lfEefyr fd, tkus ds fy, vkosnu ugha fd;k gS(.))}

6 Iv bl ;k fdlh vU; lHkk@lalnh; fuokZpu &{ks= ds fy, fuokZpd ukekoyh esa esjk uke igys ls gh lfEefyr ugha fd;k x;k gSA. ;k esjk uke------------------------------------- ---------jkT; ds------------------------------------fu okZpu&{ks= ds] ftlesa eSa uhps mfYyf[kr irs ij igys ls gh ekewyh rkSj ls fuokl dj jgk Fkk fuokZPkd ukekoyh esa lfEefyr dj fy;k x;k gksxk vkSj ;fn ,slk gS rks eSa vuqjks/k djrk gwa fd mls ml fuokZpd ukekoyh ls gVk fn;k tk,A. DECLARATION: I hereby declare that to the best of knowledge and belief . (i) I am a citizen of India and place of my birth is Village/Town ..District .. State . (ii) I am ordinarily resident at the address given at (h) above since.}}

7 (date, month, year). (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/ parliamentary 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 request that the same may be deleted from that electoral roll. tks mfpr u gks ml fodYi dks dkV nsAa * strike off the option not appropriate ekewyh :i ls fuokl dk iwoZ irk ;fn vU; fuokZpu {ks= ls ds vkosnu dj jgs gksa . Address of earlier place of ordinary residence (if applying due to shifting from another constituency).}

8 X`g la- House No. xyh@{ks=@LFkku Street/Area/Locality 'kgj@xzke Town/Village Mkd?kj Post Office fiu dksM Pin Code ftyk District jkT;@la?k jkT; {ks= State/UT. eSa bl ckr ls foK gwa fd ,slk dFku ;k ?kks" djuk] tks feF;k gS] ftlds izfr eSa ;g tkurk gwa ;k fo'okl djrk gwa fd og feF;k gS ;k mlds lR; gksus dk eq>s fo'okl ugha gS] yksd izfrfuf/kRo vf/kfu;e] 1950 1950 dk 43 dh /kkjk 31 ds v/khu naMuh; gSA. I am aware that making a statement or declaration which is false and which I know or believe to be false or do not believe to be true, is punishable under Section 31 of the Representation of the People Act, 1950 (43 of 1950). LFkku Place ---------------------------------------- ---- rkjh[k Date------------------------------------ ----------- vkosnd ds gLRkk{kj ---------------------------------------- ------ - Signature of Applicant {ks= Lrjh; lR;kiu vkfQlj dh ;ka %.}}}}

9 Remarks of Field Level Verifying Officer: dh xbZ dkjZokbZ ds C;kSjs Details of action taken fuokZpu {ks= ds fuokZPkd jftLV vkfQlj n~okjk Hkjk tk,xk . (To be filled by Electoral Registration Officer of the constituency). Jh@Jherh@dqekjh ---------------------------------------- -------------------------------- ds fuokZPkd ukekoyh esa uke dks lfEefyr djus ds iz:i 6 esa vkosnu dks Lohdkj@vLohdkj fd;k x;k gSA Lohdkj djus ds [fu;e 18@20@26 4 ds v/khu ;k esa ] ;k fu;e 17@20@26 4 ds v/khu vLohdkj] foLr`r uhps fn, x, gSa %. The application of Shri / Shrimati/ Kumari ..for inclusion of name 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 [under or in pursuance of rule 17/20/26(4)] are given below: LFkku% Place rkjh[k % Date bZvkjvks ds gLrk{kj bZvkjvks dh eqgj Signature of ERO Seal of the ERO.}}

10 &&&&&&&&&&&&&&&&&&&&& &&&&&&&&&&&&&&&&&&&&&&&&&&&&. fy, x, fofu'p; dh lalwpuk fuokZPku {ks= ds fuokZpd jftLV vkfQlj n~okjk Hkjk tkuk gS vkSj vkosnd n~okjk fn, x, irs ij vkosnd dks Mkd ls Hkstk tkuk gS . Intimation of decision taken (to be filled by Electoral Registration Officer of the constituency and to be posted to the applicant on the address as given by the applicant). Jh@Jherh@dqekjh ---------------------------------------- ---------------------------------------- ------------- dk iz:i 6 esa vkosnu fuokZpd The application in Form 6 of Shri/Shrimati/Kumari . izkf/kdkjh }kjk izs" ds le; Mkd fVdV. pLik fd, tkus gSa Postage Stamp to be affixed by the orZeku irk] ftl ij vkosnd ekewyh :i ls fuokl djrk gS x`g la- Electoral Current address where applicant is ordinarily resident Registration House No.