Form6

I request that my name be included in the electoral roll for the above Constituency.

As a first time voter

due to shifting from another constituency

Particulars in support of my claim for inclusion in the electoral roll are given below:-

(a)Name *

(b)Surname (If any)

(c)Name of Relative of Applicant *

Surname of Relative of Applicant

(d)Type of Relation *

(e)Age [as on 1st January of current calendar year] *

(f)Date of Birth (in DD/MM/YYYY format)(if known) *

(g)Gender of Applicant *

House No.

Street/Area/Locality *

Town/Village *

Post Office *

Pin Code *

State/UT *

District *

House No.

Street/Area/Locality *

Town/Village *

Post Office *

Pin Code *

State/UT *

District *

Disability (if any)(k) (Tick appropriate box)

Visual impairment

Speech & hearing disability

Locomotor disability

Other

(l) Email id (optional)

(m) Mobile No. (optional)

+91

Your Photograph *

Age Proof *

Type Of Document *

Address Proof *

Type Of Document *

I hereby declare that to the best of knowledge and belief -

(i) I am a citizen of India and place of my birth is

(ii) I am ordinarily resident at the address given at (h) above since

Date *

(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

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.

Address of earlier place of ordinary residence (if applying due to shifting from another constituency)

State *

Assembly/Parliamentary Constituency *

House No. House No & House Name

Street/Area/Locality *

Town/Village *

Post Office *

Pin Code *

District *

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).

Form 6