ELECTION COMMISSION OF INDIA /ϪÂa nj®jš Miza«

FORM-6 / got«-6
(See Rules 13(1) and 26) of Registration of Electors Rule-1960 [th¡fhs® gÂÎ éÂfŸ, 1960-‹ é 13(1) k‰W« 26-I fh©f]
Acknowledgement No/x¥òif v©.________________________
(To be filled by office/ mYtyf ga‹gh£o‰fhf)
Application for Inclusion of Name in Electoral Roll for First time Voter OR on Shifting from One Constituency to Another Constituency /
th¡fhs® g£oaèš Kjš Kiw bga® nr®¥gj‰fhd mšyJ xU bjhFÂæš ÏUªJ k‰bwhU bjhF¡F tÁ¥Ãl« kh¿ajhš
bga® nr®¥gj‰fhd é©z¥g«
To, The Electoral Registration Officer/th¡fhs® gÂÎ mÂfhç,
………………..………………………………………... Assembly Constituency/r£l¥nguit bjhFÂ

I request that my name be included in the electoral roll for the above Constituency/nk‰F¿¥Ã£l
bjhF¡fhd th¡fhs® g£oaèš vdJ bgaiu¢ nr®¤J¡ bfhŸS«go nf£L¡ bfhŸ»nw‹. (Tick SPACE FOR PASTING ONE
appropriate box/ bghU¤jkhd f£l¤Âš  F¿æLf) RECENT PASSPORT SIZE
PHOTOGRAPH (3.5 CM X
As a first time voter/ or due to shifting from another constituency/ 3.5 CM) SHOWING
Kjš Kiw th¡fhsuhf mšyJ ntbwhU bjhFÂæèUªJ tÁ¥Ãl« kh¿aj‹fhuzkhf FRONTAL VIEW OF FULL
Particulars in support of my claim for inclusion in the electoral roll are given below/th¡fhs® g£oaèš bga® FACE WITHIN THIS BOX
nr®¥gj‰fhd v‹Dila nfhç¡if¡F Mjuthd étu§fŸ ÑnH bfhL¡f¥g£LŸsd:- Kf¤Â‹ KGikahd
K‹òw¤ njh‰w¤ij¡
Mandatory Particulars / f£lha« më¡f¥gl nt©oa étu§fŸ fh£L»‹w,
fl΢ ӣL msΟs
(a) Name/ (in Tamil) (3.5br.Û X 3.5 br.Û)
bga® (jäêš) m©ikæš vL¡f¥g£l
òif¥gl« x‹¿id
(in English) f£l¤Â‰FŸ
(M§»y¤Âš) x£Ltj‰fhd Ïl«

(b) Surname (in Tamil)

(jäêš)
(if any) / (in English)
FL«g¥bga® (M§»y¤Âš)
(VnjDäU¥Ã‹)
(c) Name and surname of Relative of (in Tamil)
Applicant/é©z¥gjhuç‹ cwéd® (jäêš)
bga® k‰W« FL«g¥bga® [see item
(d)/Ïd« (o)ia¡ fh©f] (in English)
(M§»y¤Âš)

(d) Type of Relation/ Father/jªij Mother/jhŒ Husband/fzt® Wife/kidé

cwédç‹ tif (Tick
appropriate box/ Other/Vidnah®
bghU¤jkhd f£l¤Âš
 F¿æLf)
st
(e) Age [as on 1 January of current calendar year………………..] Years/M©LfŸ Months/ khj§fŸ
taJ (......M« el¥ò M©o‹ rdtç 1-M« njÂa‹W taJ)

(f) Date of Birth (in DD/MM/YYYY format)(if known)

Ãwªj nj (ehŸ/khj«/M©L) (bjçªÂUªjhš)
(g) Gender of Applicant (Tick appropriate box) Male/M© Female/bg© Third Gender/_‹wh« ghèd«
é©z¥gjhuç‹ ghèd« (bghU¤jkhd
f£l¤Âš  F¿æLf)
(h)Current address where applicant is ordinarily resident House No.
rhjhuzkhf FoæUªJ tU« Ïl¤Â‹ étu§fŸ Å£o‹ v©.
Street/Area/Locality
bjU/gFÂ/t£lhu«
Town/Village efu«/»uhk«:
Post Office/ mŠrš Pin Code
mYtyf«: mŠrš
F¿p£L
v©:
District/ State/UT
kht£l« khãy«/ôåa‹ Ãunjr«
(i) Permanent address of applicant/ House No./ Å£o‹ v©.
é©z¥gjhuç‹ ãuªju Kftç
Street/Area/Locality
bjU/gFÂ/t£lhu«

Town/Village/ efu«/»uhk«:

Post Office/ mŠrš mYtyf«: Pin Code

mŠrš F¿p£L v©:
District/ State/UT
kht£l« khãy«/ ôåa‹
Ãunjr«
(j)EPIC No. (if issued)
th¡fhs® òif¥gl milahs m£il .v©
(tH§f¥g£oUªjhš)
Optional Particulars/ éU¥òçik étu§fŸ

(k) Disability (if any) Visual impairment/f© gh®it m‰nwh®

Ïayhik (VnjD« Speech & hearing disability/ng¢R k‰W« nf£F« Âwd‰wt®
ÏU¥Ã‹) Locomotor disability/clèa¡f Ïayhik
(Tick appropriate box / Other/Ãw fhuz§fŸ
(bghU¤jkhd f£l¤Âš  F¿æLf)

(l) Email id (optional) /

ä‹dŠrš Kftç
(éU¥òçik rh®ªjJ)

(m) Mobile No. (optional)/

if¥ngÁ v©.
(éU¥òçik rh®ªjJ)

DECLARATION - I hereby declare that to the best of knowledge and belief –

(i) I am a citizen of India and place of my birth is Village/Town…………………………..…….District………………………..……State…………………………………
(ii) I am ordinarily resident at the address given at (h) above since ……………………………….……………………………….………(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
*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 request that the same may be deleted from that
electoral roll.

* strike off the option not appropriate/ bghU¤jk‰witfis mo¤JélΫ

eh‹ äf e‹whf m¿ªjtifæY« k‰W« e«ò»w tifæY« Ñœ¡f©lthW cW më¡»nw‹:-
(i) eh‹ xU ϪÂa¡ Fokf‹/Ÿ v‹ Ãwªj Ïl« »uhk«/ efu«_____________________kht£l« _______________khãy«
(ii) nkny F¿¥Ã£LŸs g¤Â (h) Kftçæš ______________š (ehŸ, khj«, tUl«) Kj‰bfh©L eh‹ rhjhuzkhf FoæUªJ
tU»nw‹;
(iii) ntW vªj bjhF¡fhd th¡fhs® g£oaèY« v‹ bgaiu¢ nr®¤J¡ bfhŸS«go eh‹ é©z¥Ã¡féšiy;
(iv)*Ϫj r£lk‹w¤ bjhF mšyJ ntbwªj r£lk‹w¤ bjhF¡fhd th¡fhs® g£oaèY« v‹ bga® V‰bfdnt
nr®¡f¥gléšiy
mšyJ
*......................................... khãy¤Â‹ ..................................................................................... bjhF¡fhd th¡fhs® g£oaèš eh‹ K‹ò
rhjhuzkhf FoæUªJtªj Ñœ¡f©l Kftçæš v‹Dila bga® nr®¡f¥g£oU¡fyh«. m¥goahæ‹ mªj th¡fhs®
g£oaèèUªJ v‹Dila bgaiu Ú¡»éL«go nf£L¡bfhŸ»nw‹.
Address of earlier place of ordinary residence (if applying due to shifting from another constituency)/é©z¥gjhuç‹ Kªija Kftç
(ntbwhU r£l¥nguit¤ bjhFÂæèUªJ Ïl« bga®ªJ é©z¥Ã¥gjhæUªjhš)

House No. / Å£o‹ v©. Street/Area/Locality

bjU/gFÂ/t£lhu«
Town/Village / efu«/»uhk«:
Post Office/ mŠrš mYtyf«: Pin Code /
mŠrš F¿p£L v©:
District / kht£l« State/UT
khãy«/ ôåa‹
Ãunjr«

I am aware that making a statement or declaration which is false and which I know or believe to be false or do not believe to
be true, is punishable under Section 31 of the Representation of the People Act, 1950 (43 of 1950) / bghŒahd mšyJ
bghŒahdbj‹W eh‹ m¿ªJŸs mšyJ e«ò»w mšyJ c©ikahdbj‹W e«ghj m¿¡ifia mšyJ cWÂbkhêia bfhL¤jhš eh‹
1950M« M©o‹ k¡fŸ ÃuÂã¤Jt¢ r£l¤Â‹ (1950‹ 43) 31tJ Ãçé‹Ñœ j©o¡f¥gl¤j¡ftdhnt‹ v‹gij eh‹ m¿nt‹.

Place/Ïl«……………........................
Date /ehŸ……………………………………. Signature of Applicant/é©z¥gjhuç‹ ifbah¥g«……….………………………………….

Remarks of Field Level Verifying Officer/ fs érhuiz mYtyç‹ F¿¥òfŸ:

Details of action taken /elto¡if vL¡f¥g£l étu«

(To be filled by Electoral Registration Officer of the constituency)
(bjhFÂæ‹ th¡fhs® gÂÎ mÂfhçahš ãu¥g¥glnt©L«)

The application of Thiru / Tmt/ Selvi …………………………………………………………………………………………………………for correction of entry in the

electoral roll in Form 6 has been accepted/rejected.
ÂU/ÂUkÂ/bršé ……………………………………………………………‹ th¡fhs® g£oaš gÂit ÂU¤Jtj‰fhd got« 6š é©z¥g«
V‰W¡bfhŸs¥g£lJ*/ ãuhfç¡f¥g£lJ*

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)] are
given below / V‰W¡bfhŸs¥gLjY¡fhd [é 18/20/ 26(4) -‹ Ñœ mšyJ ãuhfç¡f¥gLjY¡fhd éÂfŸ [17/20/26(4) -‹ Ñœ
fhuz§fŸ:

Place/ Ïl«:
Date/ ehŸ: Signature of ERO Seal of the Electoral Registration Officer
th¡fhs® gÂÎ mÂfhçæ‹ ifbah¥g« th¡fhs® gÂÎ mÂfhçæ‹ K¤Âiu
Intimation of decision taken (to be filled by Electoral Registration Officer of the constituency and to be posted to the
applicant on the address available in the record) / elto¡if vL¡f¥g£l étu« (bjhFÂæ‹ th¡fhs® gÂÎ mÂfhçahš
ãu¥g¥g£L, é©z¥gjhuuhš bfhL¡f¥g£l Kftç¡F mD¥g¥glnt©L«)

The application in Form 6 of Thiru/Tmt/Selvi………………………………………………………………………………………………………

ÂU/ ÂUkÂ/bršé ………………………………………………………………………………..Mš got« 6-Ïš më¡f¥g£l é©z¥gkhdJ Postage Stamp to be affixed by
the Electoral Registration
Authority at the time of
dispatch
Current address where applicant is ordinarily resident/ House No/ mD¥òifæ‹ nghJ
é©z¥gjhu® j‰nghJ rhjhuzkhf tÁ¡F« Kftç Å£o‹ v©. th¡fhs® gÂÎ
mYtyf¤jhš jghš
éšiy x£l¥gl
Street/Area/Locality nt©L«.

bjU/gFÂ/t£lhu«

Town/Village
efu«/»uhk«:
Post Office/ mŠrš Pin Code
mYtyf«: mŠrš
F¿p£L
v©:

District/ State/UT
kht£l« khãy«
/ôåa‹
Ãunjr«
has been (a) accepted and the name of Thiru/Tmt/Selvi …………………………………………………………………………………………………
has been registered at Serial No………………….in Part No…………………….. of AC No…………………………………………………………………….
(b) rejected for the reason……………………………………………………………………………………………………………………………………………………….
(m) V‰f¥g£L, ÂU/ ÂUkÂ/ bršé ……………………………………………………...‹bga® tçir v©.…………….ghf« v© …………….
Ïš gÂÎ brŒa¥g£LŸsJ.
(M) ………………………… ………..………… ..…………………………… v‹w fhuz¤Â‰fhf ãuhfç¡f¥g£LŸsJ.

Date/ehŸ:
Electoral Registration Officer/ th¡fhs® gÂÎ mÂfhç.
(Address)/ (Kftç)...............

Acknowledgement/Receipt/ x¥òif / uÓJ

Acknowledgement Number/ x¥òif¢Ó£L v© _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date/ehŸ __ _ _ _ _ _ _ _ _ _ _ _ _

Received the application in form 6 of Thiru / Tmt /Selvi/ ÂU/ ÂUkÂ/bršé …………………………………………..…………………………………..
ÏläUªJ got« 6 bg‰W¡ bfhŸs¥g£lJ.
[Applicant can refer the Acknowledgement No. to check the status of application]/ [é©z¥g¤Â‹ ÛJ vL¡f¥g£l elto¡ifæid
bjçªJbfhŸs x¥òif v©iz ga‹gL¤jyh«].

Name/Signature of ERO/AERO/BLO
th.g.m / c.thg.m/th.rh.ã.m bga®/ ifbah¥g«