4/7/2018 Print Acknowledgement F6i

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FORM 6i
[See rule 13(1) and 26]
Application for Inclusion of Name in Electoral Roll
Application No. : 2450829 Applicant's Copy

To  
          The Electoral Registration Officer,
      151-K R Puram Assembly Constituency
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:

I. Applicant Details
First Time Voter
First Name: DAKSH Last Name: BAJAJ
Age as on 1st Jan: 2018 31 Years and 4 Months Date Of Birth,If known:
11/09/1986 Gender: Male

Disabilities:

NOKHA NOKHA
Taluk:
BIKANER RAJASTHAN
Place Of Birth: Town/Village:
MANDI District: State:

* Father's/Mother's/Husband's Name: BAJRANG LAL

Father's First Name:
Father's Last Name:
BAJAJ
II. Particulars of place of present ordinary Residence (Full Address)
House/Door No.: 49,50

Street/Area/Locality: 1ST MAIN, 10TH CROSS , 2ND FLOOR, PAI LAYOUT

Town/Village:

Post Office: Doorvaninagar Pincode: 560016

Tehsil/Taluk/Mandal: -

District: BANGALORE

III. Details of member(s) of applicant’s family already included in the current Electoral Roll of the Constituency
Part Number of the Elector's Photo
Name: Relationship: Other Roll of the
Serial Number in
0 Identity Card
Constituency: 0 Part:
Number:

Part Number of the Elector's Photo

Name: Relationship: Other Roll of the
Serial Number in
0 Identity Card
Constituency: 0 Part:
Number:

IV. Declaration
I here by declare that to the best of my knowledge and belief:
          (i) I am a citizen of India;

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4/7/2018 Print Acknowledgement F6i

          (ii) I am ordinarily resident at the address given in Para II above since (date,month,year); 01/06/2014
          (iii) I have not applied for the inclusion of my name 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 request that the same may be
          deleted from that Electoral Roll.

Full Address(Earlier Place of Ordinary Residence): Electors Photo Identity Card Number
(If already issued)

---------- Date of Issue:

Place: BANGALORE
Date: 07/04/2018
Signature or Thumb Impression of the Applicant

A) 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).
*Strike out the inappropriate alternative

Details of Action Taken

(To be filled by Electoral Registration Officer of the Constituency)

The Application of Shri/Smt/Kum   DAKSH BAJAJ

  for inclusion of name in the Electoral Roll in Form 6i 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)£]

Place:
Date:                                   Signature of Electoral Registration Officer     (Seal of Electoral Registration Officer)

£ During continuous updating after final publication of Electoral Roll.

*Strike out the inappropriate alternative.

Remarks of Field Level Officers (ex: BLO, Designated Officer,Supervisory Officer)

List of Document Enclosed:

I.                                                     II.                                                     III.                               

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4/7/2018 Print Acknowledgement F6i

FORM 6i
[See rule 13(1) and 26]
Application for Inclusion of Name in Electoral Roll

Application No. : 2450829 ERO/AERO Copy

To  
          The Electoral Registration Officer,
      151-K R Puram Assembly Constituency
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:

I. Applicant Details
First Time Voter
First Name: DAKSH Last Name: BAJAJ
Age as on 1st Jan: 2018   31 Years and 4 Months Date Of Birth,If known:
11/09/1986 Gender: Male

Disabilities:

NOKHA NOKHA
Taluk:
BIKANER RAJASTHAN
Place Of Birth: Town/Village:
MANDI District: State:

* Father's/Mother's/Husband's Name: BAJRANG LAL

Father's First Name:
Father's Last Name:
BAJAJ
II. Particulars of place of present ordinary Residence (Full Address)
House/Door No.: 49,50

Street/Area/Locality: 1ST MAIN, 10TH CROSS , 2ND FLOOR, PAI LAYOUT

Town/Village:

Post Office: Doorvaninagar Pincode: 560016

Tehsil/Taluk/Mandal: -

District: BANGALORE

III. Details of member(s) of applicant’s family already included in the current Electoral Roll of the Constituency
Part Number of the Elector's Photo
Name: Relationship: Other Roll of the
Serial Number in
0 Identity Card
Constituency: 0 Part:
Number:

Part Number of the Elector's Photo

Name: Relationship: Other Roll of the
Serial Number in
0 Identity Card
Constituency: 0 Part:
Number:

IV. Declaration
I here by declare that to the best of my knowledge and belief:
          (i) I am a citizen of India;

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4/7/2018 Print Acknowledgement F6i

          (ii) I am ordinarily resident at the address given in Para II above since 01/06/2014
(date,month,year);
          (iii) I have not applied for the inclusion of my name 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 request that the same may be
          deleted from that Electoral Roll.

Full Address(Earlier Place of Ordinary Residence): Electors Photo Identity Card Number
(If already issued)

---------- Date of Issue:

Place: BANGALORE
Date: 07/04/2018
Signature or Thumb Impression of the Applicant

A) 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).
*Strike out the inappropriate alternative.

Details of Action Taken

(To be filled by Electoral Registration Officer of the Constituency)
The Application of Shri/Smt/Kum   DAKSH BAJAJ
  for inclusion of name in the Electoral Roll in Form 6i 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)£]
Place:
Date:                                   Signature of Electoral Registration Officer     (Seal of Electoral Registration Officer)

£ During continuous updating after final publication of Electoral Roll.

*Strike out the inappropriate alternative

Remarks of Field Level Officers (ex: BLO, Designated Officer,Supervisory Officer)

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4/7/2018 Print Acknowledgement F6i

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List of Document Enclosed:

I.                                                     II.                                                     III.                               

Details of Applicant:
Email Address: cajaibajaj@gmail.com Mobile Number: 9740019508
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Please Note: Sign and Send the ERO/AERO Copy with supporting Documents to the
respective ERO

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