Application for inclusion of name in electoral roll ApplicationID: 19713378

To, The Electoral Registration Officer *Assembly Constituency: Penamaluru 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's Details:
Name: POORNIMA
: :

Surname(if any): MASANAM

Date of birth if Day:03 Month:02 Year:1991 Gender: you know: Age as on 1st January 2013: Year:21 Months:10

Place of birth Place of birth

Village/ Town: District: ELURU WEST GODAVARI State: ANDHRA PRADESH

Relation Details
Relation Type F Father's/Mother's/Husband's: Name: Surname(if any): SATYANARAYANA MASANAM
: :

II. Particulars of place of present ordinary Residence(Full address)

House/Door number:

3-3/1
//: /: /:

Street /Area VISHNUPURAM /Locality COLONY /Mohalla /Road: Town/ Village: PORANKI

Tehsil/ Taluka/Mandal/ PENAMALURU Thana: District: KRISHNA

Post Office:

PORANKI

Pin code: 521137

III. Details of member(s) of applicant's family already included in the current electoral roll of the Constitutency:
Name: Relationship with applicant: RPart number Serial of the roll of number in the the Part: Constitutency: 0 0 Remarks: Mobile No: 9493800080 EmailId: poornima.masanam@gmail.com
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Elector's Photo Identity Card Number:

1. 2.

0 0