Tamil Nadu Elections Department Online Enrollment

FORM 6 [See rules 13(1) and 26] Application for inclusion of name in Electoral Roll (** -- indicates compulsory) *** -- Type a word in English and press SPACE to transliterate between English and Tamil Select District Select Assembly Constituency I. Applicants Details Name** $ *** Sur Name(if any) %&'($ (,-.(/0 )*** ,-.(/0 Age as on 1st January 2012 ** Sex** Years
Select Years Choose District

Months

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Select Sex

Date of Birth, if known

Select day

Select Month

Select Year

Village/Town : Place of Birth District State : : : : :

-=? $A CSelect State

5' ' 5'/' /2 ' '*** <' =' Name Surname Relationship
Select Relationship

Father's /Mother's/Husband's Name

$ %&'($ AF
AF $A C

2 C/$ $ 2/C $ $***

II. Particulars of place of ordinary residence (Full Address) House / Door Number ** Flat Name/ Building Name Street/Area/Locality/Mohalla/Road** Town / Village ** New No. Old No.

Town / Village ** II. %GH.2I .' ?J0 KLM (FN FP )*** FN &R%G %GH.(/0 <G?J0 $ %GH.(/0/ . %J '/ : ** ./ %J/' ' /5' ** 5' Post Office Name and Pincode Tehsil/Taluka/Mandal/Thana : S /T' /<' : *** T' <' Telephone STD CODE Land Line Number Mobile Number

Pincode

E-Mail**

Photo Upload (Maximum size 350kb) **

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III. Details of member(s) of applicants family already included in the current electoral roll of the Constituency Part number of the Relationship with Serial number in that Photo Identity Card Name roll of the applicant part Number constituency

IV. Declaration (fill either a or b) a) I here by declare that to the best of my knowledge and belief: i) I am a citizen of India; ii) I am ordinarily resident at the address given in para II above since Select Day Select Month Select 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) b) My name may have been included in the electoral roll for constituency in Select State 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 No. if issued Date of Issue(dd/mm/YYYY)

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