FORM 6

[See rules 13(1) and 26]

Application for inclusion of name in electoral roll

To The Electoral Registration Officer % Asse !l"# $arlia entar" &onstituenc"' Sir( ) re*uest that " na e !e included in the electoral roll for the a!o+e &onstituenc"' $articulars in su,,ort of " clai for inclusion in the electoral roll are gi+en !elo-. I. Applicants details /a e 2ears. 3onths. 3onth.
S$A&E 9OR $AST)/C O/E RE&E/T $ASS$ORT S)DE $;OTOCRA$; (3'E &3 F 3'E &3) S;OG)/C 9RO/TA< 7)EG O9 9=<< 9A&E G)T;)/ T;)S HOF

Surna e (if an") Se4 ( ale#fe ale#others). 2ear. State. Surna e (if an") II. Particulars of place of present ordinary Residence (Full address)

Age as on 1st 0anuar" '1 5ate of !irth( if 6no-n. 5a". $lace of 7illage# To-n. !irth. 5istrict. 8 9ather:s# /a e 3other:s# /a e ;us!and:s ;ouse# 5oor nu !er. Street# Area#<ocalit"# 3ohalla#Road. To-n# 7illage. $ost Office.

$in &ode.

Tehsil# Talu6a# 3andal# Thana. 5istrict. III. Details of member(s) of applicants family already included in the current electoral roll of the
onstituency.

/a e

Relationshi, -ith a,,licant

$art nu !er of the roll of the &onstituenc"

Serial nu !er Elector:s $hoto )dentit" &ard in that $art /u !er

1' 2'
%

)n case of =nion territories ha+ing no <egislati+e Asse !l" and the State of 0a ?ash ir' 1 $lease gi+e the "ear i'e' 2@@A( 2@@B( etc' 8 Stri6e out the ina,,ro,riate alternati+e

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I!. Declaration
) here!" declare that to the !est of " 6no-ledge and !elief. I

(i) (ii)

I am a citizen of India; I am ordinarily resident at the address given in para II above since .. (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 constituency;

*My name may have been included in the electoral roll for !onstituency in "tate in #hich I #as ordinarily resident earlier at the address mentioned belo# and if so, I re$uest that the same may be deleted from that electoral roll.
9ull Address (Earlier $lace of ordinar" residence) JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJJJJJ $lace. 5ate. Electors $hoto )dentit" &ard nu !er (if alread" issued)JJJJJJJJJJJJJJJJJJJJ 5ate of issue JJJJJJJJJJJJJJJJJJJJJ

Or

Signature or thu ! i ,ression of the a,,licant $lease gi+e "our o!ile nu !er #EI ail )'5 (O,tional)#'' A) "ote Any person who makes a statement or declaration which is false and which he either knows or believes to be false or does not believe to be true, is punishable under Section 31 of the Representation of the People Act, 19 ! "#3 of 19 !$% 8 Stri6e out the ina,,ro,riate alternati+e' Details of action ta#en ($o be filled by %lectoral Re&istration Officer of the constituency) The a,,lication of Shri#S t'#? ''for inclusion of na e in the electoral roll in 9or 6 has !een acce,ted8#reKected8' % 5etailed reasons for 8acce,tance [under or in ,ursuance of rule 1B8#2@8#26(L)] or8 reKection [under or in ,ursuance of rule 1A#2@8#26(L) ].
%

$lace. 5ate Signature of Electoral Registration Officer % 5uring continuous u,dating after final ,u!lication of electoral roll' 8 Stri6e out the ina,,ro,riate alternati+e' (Seal of the Electoral Registration Officer)

Remar#s of Field 'e(el Officers (e.& )'O* Desi&nated Officer* +uper(isory Officer)
[9OR3 6 &ontd'']

[$his pa&e should be thic# enou&h so that it does not &et mutilated ,dama&ed in postal transit] Intimation of action ta#en (+ection-II of the pa&e is to be filled by %lectoral Re&istration Officer of the constituency and to be posted to the applicant on the address as &i(en by the applicant in +ection-I)
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII9irst 9oldIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII

SectionI)
$ostage Sta , to !e affi4ed !" the Electoral Registration Authorit" at the ti e of dis,atch

The a,,lication in 9or 6 of 88Shri# Shri ati# ?u ari''''''''

** (Full address)
;ouse# 5oor nu !er. Street# Area#<ocalit"# 3ohalla#Road. To-n# 7illage. $ost Office. Tehsil# Talu6a# 3andal# Thana. 5istrict. 88 To !e filled in !" the a,,licant' IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIISecond 9oldIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII SectionI)) has !eenM (a) acce,ted and the na e of Shri#Shri ati#?u ari'''''''''''''''''has !een registered at Serial /o'''''in $art /o'''''''''''''''''''' of A& /o' ' (!) reKected for the reason'''''''''''''''''''''''''' 5ate''''''''''''''''''''''' Electoral Registration Officer' (Address)'''''''''''''''''

$in &ode.

''''''''''''''''''''''''' '''''''''''''''''''''''''' ''$erforation for detach ent

Receipt for application Recei+ed the a,,lication in 9or 6 of 88 Shri#Shri ati#?u ari'' 88Address 5ate 88 To !e filled in !" the a,,licant' Signature of the officer recei+ing the a,,lication on !ehalf of the Electoral Registration Officer (Address) '

C=)5E<)/ES 9OR 9)<<)/C =$ T;E A$$<)&AT)O/ 9OR3I6 .eneral Instructions /ho can file Form-6 1' 2' 9irst ti e a,,licant on attaining age of 1B"ears or ore on the first da" of 0anuar" of the "ear -ith reference to -hich the electoral roll is !eing re+ised' $erson shifting his # her ,lace of ordinar" residence outside the constituenc" in -hich he # she is alread" registered'

/hen Form-6 can be filed 1' The a,,lication can !e filed after draft ,u!lication of electoral roll of the constituenc"' The a,,lication is to !e filed -ithin the s,ecific da"s ,ro+ided for the ,ur,ose' 5ue ,u!licit" is gi+en a!out the a!o+e ,eriod -hen the re+ision ,rogra e is announced' Onl" one co," of the a,,lication is to !e filed' A,,lication for inclusion of na e can !e filed through out the "ear e+en -hen the re+ision ,rogra not going on' 5uring nonIre+ision ,eriod( a,,lication ust !e filed in du,licate' e is

2' 3'

/here to file Form-6 1' 5uring re+ision ,eriod( the a,,lication can !e filed at the designated locations -here the draft electoral roll is dis,la"ed ( ostl" ,olling station locations) as -ell as the Electoral Registration Officer and Assistant Electoral Registration Officer of the constituenc"'

2'

5uring other ,eriod of the "ear -hen re+ision ,rogra -ith the Electoral Registration Officer'

e is not going on( the a,,lication can !e filed onl"

0o1 to Fill the Form-6 1' 2' The a,,lication should !e addressed to the Electoral Registration Officer of the constituenc" in -hich "ou see6 registration' The na e of the constituenc" should !e entioned in the !lan6 s,ace' /a e (Gith 5ocu entar" $roof) The na e as it should a,,ear in the electoral roll and Electors $hoto )dentit" &ard (E$)&) should !e furnished' The full na e e4ce,t the surna e should !e -ritten in the first !o4 and surna e should !e -ritten in the second !o4' )n case "ou do not ha+e a surna e( Kust -rite the gi+en na e' &aste should not !e entioned e4ce,t -here the caste na e is used as ,art of the elector:s na e or a surna e' ;onorific a,,ellations li6e Shri( S t' ?u ari( ?han( Hegu ( $andit etc' should not !e entioned'

Age (Gith 5ocu entar" $roof) The age of the a,,licant should !e eighteen or ore on 1st 0anuar" of the "ear -ith reference to -hich the electoral roll is !eing re+ised' The age should !e indicated in "ears and onths' e'g' A ,erson !orn on or u,to 1#1#1NN1 -ill !e eligi!le for inclusion in the electoral roll -hich is !eing re+ised -ith reference to 1#1#2@@N' $ersons !orn on 2#1#1NN1 or thereafter u,to 1#1#1NN2 shall !e eligi!le for inclusion during the ne4t re+ision -ith reference to 1#1#2@1@' L' Se4 Grite "our se4 in full in the s,ace ,ro+ided e'g' 3ale # 9e ale' Eunuchs ha+e to choose fro o,tions' one of these

3'

E'

5ate of Hirth (Gith 5ocu entar" $roof) 9ill u, the date of !irth in figures in the s,ace ,ro+ided in dd# #""""' $roof of date of !irth to !e attached are as under. (i) Hirth certificate issued !" a 3unici,al Authorities or district office of the Registrar of Hirths > 5eaths or Ha,tis certificateO or (ii) Hirth certificate fro the school (Co+t' # Recognised) last attended !" the a,,licant or an" other recognised educational institutionO or (iii) Illiterate or semi-illiterate applicant 1ho is not in possession of any of the abo(e document are re2uired to attach a declaration in prescribed format by either of the parents already included in the electoral roll in support of the applicants a&e. $he format 1ill be supplied on demand. /'H' )n the case of a,,licants !orn on or after 26'@1'1NBN( onl" !irth certificate issued !" the 3unici,al Authorities or district office of the Registrar of Hirths > 5eaths is acce,ta!le' $lace of Hirth )n case !orn in )ndia( ,lease ention na e of ,lace li6e 7illage # To-n( 5istrict( State'

6' A'

Relation:s /a e. )n case of un arried fe ale a,,licant( na e of 9ather # 3other is to !e entioned' )n case of arried fe ale a,,licant( na e of ;us!and is to !e entioned' Stri6e out the ina,,lica!le o,tions in the colu n' $lace of Ordinar" Residence 9ill u, the full and co ,lete ,ostal address including $)/ code -here "ou are ordinaril" residing and -ant to get registered( in the s,ace ,ro+ided' $roof of ordinar" residence to !e attached are as under. (i) Han6 # ?isan # $ost Office current $ass Hoo6( or (ii) A,,licants Ration &ard # $ass,ort # 5ri+ing <icense # )nco e Ta4 Assess ent Order( or (iii) <atest Gater # Tele,hone # Electricit" # Cas &onnection Hill for that address( either in the na e of the a,,licant or that of his # her i ediate relation li6e ,arents etc'( or (i+) $ostal de,art ent:s ,osts recei+ed # deli+ered in the a,,licant:s na e at the gi+en address'

B'

/OTE. )f an" a,,licant su! its onl" ration card as ,roof of address( it should !e acco ,anied !" one address out of the a!o+e categories' N'

ore ,roof of

5etails of 9a il" 3e !ers Alread" )ncluded in the Electoral Roll 3lease fill up name and other particulars of immediate family members i.e. Father , Mother , )rother , +ister , +pouse included in the current electoral roll of the constituency. "ame of any other relation li#e uncle* aunt* cousin brother , sisters etc. not to be mentioned.

1@' 5eclaration $lease indicate date fro -hich "ou are residing in the gi+en address' )n case the e4act date is not 6no-n( fillIu, onth and "ear' )f "our na e is alread" included in the electoral roll of an" other constituenc"( ,lease -rite legi!l" the full ,re+ious address -ith $)/ code' If you already ha(e been issued 1ith a 3hoto Identity ard by the %lection ommission* please mention the card number (printed on the front side) and date of issue (printed on the bac# side) of the card in the space pro(ided. 3lease attach a self-attested photocopy of both sides of the card.

Miscellaneous
)n an" ,laces the ,hotogra,h of the elector is also ,rinted in the electoral roll' 2ou ha+e the o,tion to su! it one recent coloured ,ass,ortIsiPe ,hotogra,h along-ith the for ' The ,hotogra,h -ill !e used to ,rint "our i age in the electoral roll and issue of identit" card( if re*uired' $lease also gi+e "our full na e and address on the ac6no-ledge ent and inti ation ,ortions' $lease gi+e "our o!ile nu !er and EI ail )'5 in the 9or ( -hich is o,tional ( as the sa e (if gi+en( a" !e used !" the Electoral Registration Officer for further co unication -ith the a,,licant -hene+er re*uired'