ANNEXURE -3

(For Form -6)

DECLARATION
For an elector of 21+ age seeking fresh registration for the first time

1. Floyd Correa Son of James Correa R/o of Andheri East, Mumbai, Maharashtra, India declare
as under: -
I have applied for registration in the electoral roll Andheri East constituency.
2. I have not been issued any EPIC at any time in the past in any constituency.

Place: - Mumbai Signature of Applicant

Date: -18/06/2020

(Making false in matter to preparation/revision of electoral roll is an offence

perishable under sector 31 Representation of people Act, 1951, and also the
Indian Panel code)