Application ID :

ECIS270632013Form67

/ FORM 6
[

13(1) 26

] / [See rules 13(1) and 26]

/
Application for inclusion of name in electoral roll
/ To,

photo

/ The Electoral Registration Officer,

-
- Assembly Constituency.

063

/Sir,

:i request that my name be included in the electoral roll for the above constituency. particulars in support of my claim for
inclusion in the electoral roll are given below :

1.
details

/ Applicant's
Name : M.N

1 /
Age as on 1st January 2013
,

GOURIPUR

/ Place of Birth
relationtype :

Father

1 mth(s)

/ Months :

/ Sex :

(Village/Town) : BHAGALPUR
17

District

/ State : S27

( ) :

Name : PRABHU NARAYAN

Surname (if any) : SHARMA

particulars of place of present ordinary residence (full address) :

FLAT NO 3A

: House / Door

/ / / / :

SHANTI NIKETAN APARTMENT LANE-3 ANAND GRAM

street / area / locality / mohalla / road :

/ :

RANCHI

town / village :

// /

District

MORABADI

post office :

: ( )

II.
2.

56 yr(s)

04-10-1957

: / Date of Birth, if known

/ Years :

Surname (if any) : SHARMA

834008

pin code :

: Tehsil /Taluka/Mandal/Thana :

BARIATU

RANCHI

3. :
III. Details of member(s) of applicant's family already included in the current electoral roll of the Constituency:
/ Name

/
Relationship with
applicant

1.

2.

mobile number :

/ Serial Number

/ Part Number of the roll

of the Constituency

9470596599

of in that part

e-mail address :

/
elector's photo identity
card number

helloabhishek.in@gmail.com

....................................................................................................................................................................................
....
Application ID : ECIS270632013Form678

/ Receipt for application

Received the application in Form-6 of Shri/Shrimati/Kumari M.N

Address , ,
FLAT NO 3A,SHANTI NIKETAN APARTMENT LANE-3 ANAND GRAM,RANCHI,MORABADI,834008,BARIATU,RANCHI
Date : 06-Nov-2013

Signature of the officer recceiving the application

on behalf of the Electoral Registration Officer

IV. / Declaration
/

and belief :(i)

(ii)
(iii)

: / I hereby declare that to the best of my knowledge

(, , )

(iv) *
(i)
I am a citizen of India.
(ii)
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:

/ 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 requested that the same may be deleted from that electoral roll.

(:

Full Address (Earlier place of ordinary residence) :

. ( )

BR/46/278/378255

number :

:
Place :

:
Date :

/ Electors photo Identity Card (if already

date of issue :

26-11-1995

06-11-2013

Signature or thumb impression of the applicant

, ,

1950(1950

43)

31

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)
/ Details of action taken
( )
(To be filled by Electoral Registration Officer of the constituency)
//

6 * / *

The application of Shri/Smt./Km. for inclusion of name in the electoral roll in Form 6 has been accepted*/recjected*.
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)]:
Place:
Date:

Signature of Electoral Registration Office

(Seal of the Electoral Registration Officer)

( , , ) / Remarks of Field Level

Officer (e.g. BLO, Designated Officer, Supervisory Officer.)