Application for inclusion of name in electoral roll ApplicationID:12315311

To,
The Electoral Registration Officer
*Assembly Constituency: Pathapatnam
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: USHA . a:

Surname(if any): BUDIDA . a:
c
Dateof birth if you know: Day:03 Month:10 Year:1988 Gender: F
Ageas on 1st J anuary
2013:
Year:24 Months:2
Place of birth Place of birth
Village/ Town: KAGUVADA
District: SRIKAKULAM State: ANDHRAPRADESH
Relation Details
Relation Type
Father's/Mother's
/Husband's:
H
Name: KRISHNA .a:
s
Surname(if any): BUDIDA . a:
c
II. Particulars of place of present ordinary Residence(Full address)
House/Door number: 7-17
Street /Area /Locality
/Mohalla /Road:
VASTRAPURI COLONY Dc o 's0:
yo s
Town/ Village: KAGUVADA n :
s:c
Tehsil/ Taluka/Mandal/
Thana:
Pathapatnam c :
`_
District: SRIKAKULAM Post Office: KORASAVADA
Pin code: 532214
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 of the
roll of the
Constitutency:
Serial number in the
Part:
Elector's Photo Identity
Card Number:
1. 0 0
2. 0 0
Mobile No: 7702423352 Remarks:
Email-Id: