PART NO :0 Application ID :

/ FORM 6
112158715
[ 13(1) 26 ] / [See rules 13(1) and 26]

/
Application for inclusion of name in electoral roll

/ To,
/ The Electoral Registration Officer,
53 - (GEN)
53 - BADARPUR (GEN) Assembly Constituency.

/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 :

: ( ) :
1. / Applicant's
details Name : IMRAN Surname (if any) : KHAN
1 2017 / 20
/ Years : / Months : / Sex : Male
Age as on 1st January 2017
,
: / Date of Birth, if known 08-Oct-1996
/
(Village/Town) : jaitpur
/ Place of Birth
/ District : new delhi / State : delhi

Father's Name : : ( ) :
Name : SHAUKAT ALI Surname (if any) : KHAN
II. : ( ) :
2. Particulars of place of present ordinary residence (Full address) :

/ : House / Door No.: A-94

/ / / / :
GALI NO - 2
Street / Area / Locality / Mohalla / Road :
/ : JAITPUR PART - 2 BADARPUR
Town / Village :
: :
JAITPUR 110044
Post Office : Pin Code :
/ /
/ : Tehsil /Taluka/Mandal/Thana : NEW DELHI

/ District DELHI

3. :
III. Details of member(s) of applicant's family already included in the current electoral roll of the Constituency:

/ Name Relationship with ./

/ Part Number of the roll / Serial Number Elector's Photo Identity
applicant of the Constituency of in that part Card Number

1. 0 0

2. 0 0

Mobile Number : 9716543395 E-Mail Address : imran199210@gmail.com

....................................................................................................................................................................................
....

Application ID : 112158715 / Receipt for application

Received the application in Form-6 of Shri/Shrimati/Kumari IMRAN KHAN Address A-94, GALI NO - 2, DELHI

Date : 19-Oct-2016 Signature of the officer recceiving the application

on behalf of the Electoral Registration Officer
 IV. / Declaration
/
: / I hereby declare that to the best of my knowledge
and belief :-
(i)

(ii) :
2 01-Jan-2011 (, , )

(iii)

(iv) *
(i) I am a citizen of India.
(ii) I am ordinarily resident at the address given in para II above since 01-Jan-2011 (date, month, 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
* / /
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* My name may have been included in the electoral roll for constituency in state in which I was ordinarily resident earlier at the
/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /
address mentioned below and if so, I requested that the same may be deleted from that electoral roll.

/ / (
/ / / :/
/ / /
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/ )/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /
Full Address (Earlier place of ordinary residence) :

. ( )
/ Electors photo Identity Card (if already
Not Applicable Not Applicable
Number : Date of Issue :

: :

Place : Date : 19-Oct-2016
Signature or thumb impression of the applicant
:
,
, 1950(1950 43) 31

Note - 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, is punishable under section 31 of the Representation of the People Act, 1950 (43 of 1950)

/ Details of action taken

( )
(To be filled by Electoral Registration Officer of the constituency)

/ /
6 * /
*
The application of Shri/Smt./Km. IMRAN KHAN for inclusion of name in the electoral roll in Form 6 has been
accepted*/recjected*.

Detailed reasons for *acceptance [under or in pursuance of rule 18*/20*/26(4)] or *rejection [under or in pursuance of rule
17*/20*/26(4)]:

Place:
Date: Signature of Electoral Registration Office (Seal of the Electoral Registration Officer)

( , , ) / Remarks of
Field Level Officer (e.g. BLO, Designated Officer, Supervisory Officer.)