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    Kali Das
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    24 views3 pages

    Bilingual Version of 001 PDF

    Uploaded by

    Kali Das

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 3
    Blection Commission of India FORM ID Bu Csised ayenomith pau ID ae tanh Application for issue of Replacement Elector’s Photo Identity Card (EPIC) ECL-EPIC-001 orgy euréerani ysoatin oyeumer sm Gost tie State/UT / wonpioad /ypusir dvGa + A a ‘AC (No. & Name} /ac.osiints Gurmays Oome Suse soiree District /unecui ? B | Blector’s Particulars (To be filled by Blector) /amdananiir Daspiact (andsemorgns Oyo & | Casini) To] Guprsi ‘The Electoral Registration Officer / ardesrort uginy oySlear, Assembly / Parliamentary Constituency / acindrp Apne) / unmigsuserp Gere) Sir/Madam / jiu] oqhonndt, I request that a Duplicate Electoral Photo Identity Card be issued to me as my original card is lost/destroyed/mutilated due to corrections in my elector’s detail or due to change of acidress. I want to get a fresh card with my new address. I am returning my| EPIC to you along with fee for issue of duplicate BPIC. My| name ig included in the electoral roll for the above constituency. Particulars in support of my claim for issue of duplicate EPIC are given below: cigar sneewmod Guner | ogfiieCurer | Gegumse J] aréermfcr sSamiesh Despre GwjCensroriu Gausisips ong) yooutl nip CopDeniconbux Cossingis 2 siranuusre furéeront Ymat. QenLumar SOL upaTs umf) ardent Ussaiat gpocumen oi-sn. sugixgunpl Gor.Ok GeiniesGpsr. energy ysw Yoouflydr yw unig) eréeront yee. SjonusTeT SFO Guy aiiginSlGns. pros screen anderen? yma jpn_uter SCeLenuiy ups uTjg améenent Yoel. poLumer ys eugsionsierar ax emgsnsuth OegudgOGprir. eerepen us Guuimrengs Cope MAIL suds AprePhse Lvl. awéarort ucpwdl Guidupgring. wyg onéerert ymetu. —gencurar oxen apkgappere ségeu SainemiusS pare dipéangpsd| yonmiusenst ica SNinGper T. Name of Blector / améomonfir Quast: 2. EPIC No. of Original card (if known) / .sinemuuirer emréorent yoaCU 596oLuiTar Sj sa. cir. OxsisBipisie :- 3, Father's / Mother's / Husband's Name / , Sex (M/F) 5. Date of Birth (DOB) pfisogs |g | eorout Quut uredlemis (ayer /Gusim) | ( If not known then Age in Years as on 1* Jan, 201___ Spi GB. (Ggsfusrsuc esd 201... gone rors sdrerily L095 ahain Go GyHA943) 6. Address 7 qanit ( House / Door number / 58@/ expsftsodeth = {i Street / Mohalla / Road / Gali / Gg 1x6)! enened | HeginT td (ii) Area / Locality 7 @.0/ gyusiiub (i) Town / Village / pani / yma: () FIN CODE / Koh GHD ssi (vi) Police Station Jaman flmauia = (vii) District 7 onto = (vill) Reasons for applying for a Duplicate card / mpg andaneri ymaiu. oencuner opm 8@ Asie coriNtussberen angeans (J i. Iwill collect EPIC from VRC/CSC / rer sirgyencu eden yosiue. gja_urer fs. eu oxréesront Goraes sonwg6\Eeur/ Guirgy Comes eas Serr Quins AesrdeSlCneir 2. Iwish to receive my EPIC by Post (self addressed and stamped envelope enclosed) / prsir é tae és i rat Sioned Quins QesrsrSGper. (oweslarensict. CL aoa Gone sacuc Guten) a % Iwill collect BPIC from BLO / préradigrouu andar matin. sjeLner oy. eoL ow andes tally hom signin Asie Cups Genser. ( ) Signature of the applicant sinemigmni naGumiith (i) Tick( 7) the appropriate box / fu ac B60(¥)) pia: Date / sé: Thereby return my mutilated / old card / Sais seriou Cogs2en fs! Uno ¢

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