FORM 17A

Register of voters
[See rule 72(1)]

Election to the *………………………………………………… **Gram

Panchayat/Panchayat Samiti/Zilla Parishad/Mahakuma Parishad from the ……………
constituency, No. and name of polling station ………………………………. ……………
Part No. of electoral roll……………………….

________________________________________________________________________
___
Sl. No. Sl. No. of voter #Identification # Identification Signature / LTI
Remarks in electoral roll by EPIC by other record of
elector
________________________________________________________________________
___
(1) (2) (3) (4) (5)
(6)
________________________________________________________________________
___

________________________________________________________________________
_

Date………………………
………………………………………
Signature of Presiding
Officer

________________________________________________________________________
___

* Appropriate particulars of the election to be inserted here.

** Strike off the inappropriate alternative.
# Put tick mark in appropriate column.