FORM 6

[See rules 13(1) and 26]

Application for inclusion of name in electoral roll
To The Electoral Registration Officer % ……………………Asse !l"# $arlia entar" &onstituenc"' Sir( ) re*uest that " na e !e included in the electoral roll for the a!o+e &onstituenc"' $articulars in su,,ort of " clai for inclusion in the electoral roll are gi+en !elo-. I. Applicant’s details /a e 2ears. 3onths. 3onth.
S$A&E 9OR $AST)/C O/E RE&E/T $ASS$ORT S)DE $;OTOCRA$; (3'E &3 F 3'E &3) S;OG)/C 9RO/TA< 7)EG O9 9=<< 9A&E G)T;)/ T;)S HOF

Surna e (if an") Se4 ( ale#fe ale#others). 2ear. State. Surna e (if an") II. Particulars of place of present ordinary Residence (Full address)

Age as on 1st 0anuar" …………'1 5ate of !irth( if 6no-n. 5a". $lace of 7illage# To-n. !irth. 5istrict. 8 9ather:s# /a e 3other:s# /a e ;us!and:s ;ouse# 5oor nu !er. Street# Area#<ocalit"# 3ohalla#Road. To-n# 7illage. $ost Office.

$in &ode.

Tehsil# Talu6a# 3andal# Thana. 5istrict. III. Details of member(s) of applicant’s family already included in the current electoral roll of the
onstituency.

/a e

Relationshi, -ith a,,licant

$art nu !er of the roll of the &onstituenc"

Serial nu !er Elector:s $hoto )dentit" &ard in that $art /u !er

1' 2'
%

)n case of =nion territories ha+ing no <egislati+e Asse !l" and the State of 0a ?ash ir' 1 $lease gi+e the "ear i'e' 2@@A( 2@@B( etc' 8 Stri6e out the ina,,ro,riate alternati+e

u>

I!.riate alternati+e' Details of action ta#en ($o be filled by %lectoral Re&istration Officer of the constituency) The a. year) (iii) I have not applied for the inclusion of my name in the electoral roll for any other constituency. (date.ro..ression of the a.tance [under or in . *My name may have been included in the electoral roll for !onstituency in "tate in #hich I #as ordinarily resident earlier at the address mentioned belo# and if so. Declaration ) here!" declare that to the !est of " 6no-ledge and !elief. 9ull Address (Earlier $lace of ordinar" residence) JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJJJJJ $lace.tional)#……………………………………'' A) "ote – Any person who makes a statement or declaration which is false and which he either knows or believes to be false or does not believe to be true.. % . I am ordinarily resident at the address given in para II above since ………. (iv) *My name has not already been included in the electoral roll for this or any other assembly constituency. I (i) (ii) I am a citizen of India.lication of Shri#S t'#? ………………………………………………………………………''for inclusion of na e in the electoral roll in 9or 6 has !een acce.ursuance of rule 1B8#2@8#26(L)] or8 reKection [under or in . 19 ! "#3 of 19 !$% 8 Stri6e out the ina.. I re$uest that the same may be deleted from that electoral roll..ted8#reKected8' % 5etailed reasons for 8acce.ursuance of rule 1A#2@8#26(L) ]. 5ate.licant $lease gi+e "our o!ile nu !er #EI ail )'5 (O. is punishable under Section 31 of the Representation of the People Act. Electors $hoto )dentit" &ard nu !er (if alread" issued)JJJJJJJJJJJJJJJJJJJJ 5ate of issue JJJJJJJJJJJJJJJJJJJJJ Or Signature or thu ! i . month.

atch The a..& )'O* Desi&nated Officer* +uper(isory Officer) [9OR3 6 &ontd…''] [$his pa&e should be thic# enou&h so that it does not &et mutilated . To-n# 7illage.dating after final .dama&ed in postal transit] Intimation of action ta#en (+ection-II of the pa&e is to be filled by %lectoral Re&istration Officer of the constituency and to be posted to the applicant on the address as &i(en by the applicant in +ection-I) IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII9irst 9oldIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII SectionI) $ostage Sta .. .ro. 5istrict. $ost Office. to !e affi4ed !" the Electoral Registration Authorit" at the ti e of dis.ted and the na e of Shri#Shri ati#?u ari'''''''''''''''''has !een registered at Serial /o'''''in $art /o'''''''''''''''''''' of A& /o' ………………………………………' (!) reKected for the reason''''''''''''''''''''''''……………………''………………………………… 5ate''''''''''''''''''''''' Electoral Registration Officer' (Address)''''''''''''''''' $in &ode. 88 To !e filled in !" the a.u!lication of electoral roll' 8 Stri6e out the ina.. Street# Area#<ocalit"# 3ohalla#Road.ouse# 5oor nu !er. Tehsil# Talu6a# 3andal# Thana.$lace. 5ate Signature of Electoral Registration Officer % 5uring continuous u.licant' IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIISecond 9oldIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII SectionI)) has !eenM (a) acce.lication in 9or 6 of 88Shri# Shri ati# ?u ari'''''''' ** (Full address) .riate alternati+e' (Seal of the Electoral Registration Officer) Remar#s of Field 'e(el Officers (e.

..lication on !ehalf of the Electoral Registration Officer (Address) …………………………' C=)5E<)/ES 9OR 9)<<)/C =$ T.ose' 5ue ..eriod( the a.rogra e is announced' Onl" one co.ur.eneral Instructions /ho can file Form-6 1' 2' 9irst ti e a.E A$$<)&AT)O/ 9OR3I6 ...." of the a.licant on attaining age of 1B"ears or ore on the first da" of 0anuar" of the "ear -ith reference to -hich the electoral roll is !eing re+ised' $erson shifting his # her .rogra not going on' 5uring nonIre+ision .ro+ided for the .lication ust !e filed in du.eriod -hen the re+ision .la"ed ( ostl" .lication can !e filed after draft .u!lication of electoral roll of the constituenc"' The a.lication can !e filed at the designated locations -here the draft electoral roll is dis.ecific da"s ..lace of ordinar" residence outside the constituenc" in -hich he # she is alread" registered' /hen Form-6 can be filed 1' The a.u!licit" is gi+en a!out the a!o+e .licant' Signature of the officer recei+ing the a.lication is to !e filed' A.lication in 9or 6 of 88 Shri#Shri ati#?u ari……………………………………'' 88Address……………………………………………………………………………………… 5ate…………… 88 To !e filled in !" the a...lication is to !e filed -ithin the s.licate' e is 2' 3' /here to file Form-6 1' 5uring re+ision .''''''''''''''''''''''''' '''''''''''''''''''''''''' ………………………………………………''$erforation for detach ent……………………… Receipt for application Recei+ed the a.eriod( a.lication for inclusion of na e can !e filed through out the "ear e+en -hen the re+ision .olling station locations) as -ell as the Electoral Registration Officer and Assistant Electoral Registration Officer of the constituenc"' ..

erson !orn on or u.lication can !e filed onl" 0o1 to Fill the Form-6 1' 2' The a.licant( na e of 9ather # 3other is to !e entioned' )n case of arried fe ale a.ta!le' $lace of Hirth )n case !orn in )ndia( .lace li6e 7illage # To-n( 5istrict( State' 6' A' Relation:s /a e.licant should !e eighteen or ore on 1st 0anuar" of the "ear -ith reference to -hich the electoral roll is !eing re+ised' The age should !e indicated in "ears and onths' e'g' A .t -here the caste na e is used as ..licant( na e of .to 1#1#1NN2 shall !e eligi!le for inclusion during the ne4t re+ision -ith reference to 1#1#2@1@' L' Se4 Grite "our se4 in full in the s.licants Ration &ard # $ass.ort # 5ri+ing <icense # )nco e Ta4 Assess ent Order( or (iii) <atest Gater # Tele.lication should !e addressed to the Electoral Registration Officer of the constituenc" in -hich "ou see6 registration' The na e of the constituenc" should !e entioned in the !lan6 s.hone # Electricit" # Cas &onnection Hill for that address( either in the na e of the a.ro+ided' $roof of ordinar" residence to !e attached are as under.osts recei+ed # deli+ered in the a.ro+ided e'g' 3ale # 9e ale' Eunuchs ha+e to choose fro o. the date of !irth in figures in the s.lease ention na e of .2' 5uring other ... (i) Han6 # ?isan # $ost Office current $ass Hoo6( or (ii) A.al Authorities or district office of the Registrar of Hirths > 5eaths or Ha. $he format 1ill be supplied on demand.lica!le o.ace .ace' /a e (Gith 5ocu entar" $roof) The na e as it should a.tis certificateO or (ii) Hirth certificate fro the school (Co+t' # Recognised) last attended !" the a.al Authorities or district office of the Registrar of Hirths > 5eaths is acce. the full and co .ear in the electoral roll and Electors $hoto )dentit" &ard (E$)&) should !e furnished' The full na e e4ce.tions' one of these 3' E' 5ate of Hirth (Gith 5ocu entar" $roof) 9ill u...art of the elector:s na e or a surna e' .to 1#1#1NN1 -ill !e eligi!le for inclusion in the electoral roll -hich is !eing re+ised -ith reference to 1#1#2@@N' $ersons !orn on 2#1#1NN1 or thereafter u. /'H' )n the case of a.us!and is to !e entioned' Stri6e out the ina.ace ..licant or that of his # her i ediate relation li6e . (i) Hirth certificate issued !" a 3unici.rogra -ith the Electoral Registration Officer' e is not going on( the a.eriod of the "ear -hen re+ision . )n case of un arried fe ale a.art ent:s .ostal address including $)/ code -here "ou are ordinaril" residing and -ant to get registered( in the s......onorific a.lete ..licant or an" other recognised educational institutionO or (iii) Illiterate or semi-illiterate applicant 1ho is not in possession of any of the abo(e document are re2uired to attach a declaration in prescribed format by either of the parents already included in the electoral roll in support of the applicants a&e.t the surna e should !e -ritten in the first !o4 and surna e should !e -ritten in the second !o4' )n case "ou do not ha+e a surna e( Kust -rite the gi+en na e' &aste should not !e entioned e4ce.licants !orn on or after 26'@1'1NBN( onl" !irth certificate issued !" the 3unici..licant:s na e at the gi+en address' B' .ro+ided in dd# #""""' $roof of date of !irth to !e attached are as under.tions in the colu n' $lace of Ordinar" Residence 9ill u.arents etc'( or (i+) $ostal de.ace .ellations li6e Shri( S t' ?u ari( ?han( Hegu ( $andit etc' should not !e entioned' Age (Gith 5ocu entar" $roof) The age of the a.

not to be mentioned. sisters etc.tion to su! it one recent coloured . 1@' 5eclaration $lease indicate date fro -hich "ou are residing in the gi+en address' )n case the e4act date is not 6no-n( fillIu. +ister ./OTE.roof of address( it should !e acco . )rother . "ame of any other relation li#e uncle* aunt* cousin brother .rinted in the electoral roll' 2ou ha+e the o.ortIsiPe .roof of 5etails of 9a il" 3e !ers Alread" )ncluded in the Electoral Roll 3lease fill up name and other particulars of immediate family members i.re+ious address -ith $)/ code' If you already ha(e been issued 1ith a 3hoto Identity ard by the %lection ommission* please mention the card number (printed on the front side) and date of issue (printed on the bac# side) of the card in the space pro(ided. 3lease attach a self-attested photocopy of both sides of the card. Father .e.ass.hotogra. onth and "ear' )f "our na e is alread" included in the electoral roll of an" other constituenc"( ..licant -hene+er re*uired' .hotogra.hotogra.lease -rite legi!l" the full .laces the . Mother .anied !" one address out of the a!o+e categories' N' ore .rint "our i age in the electoral roll and issue of identit" card( if re*uired' $lease also gi+e "our full na e and address on the ac6no-ledge ent and inti ation .h -ill !e used to .h along-ith the for ' The . +pouse included in the current electoral roll of the constituency. )f an" a..licant su! its onl" ration card as .ortions' $lease gi+e "our o!ile nu !er and EI ail )'5 in the 9or ( -hich is o.h of the elector is also .tional ( as the sa e (if gi+en( a" !e used !" the Electoral Registration Officer for further co unication -ith the a. Miscellaneous )n an" .