Inclusion of Name in the Electoral Rolls (Form-6)

Assembly constituency Details

District*: _____________________ Assembly Constituency Name*: _____________________

Applicant's Details:
AADHAR Card No: __________________________ Applicant Name*: ___________________

Surname*: ______________________________ Gender*: ___________________________

Relation*: ________________________ Guardian's Name*:___________________________

Guardian's SurName*:_______________ Date of Birth (dd/mm/yyyy)*:___________________

Serial Number in the Part*:__________________ Mobile No*: ___________________________

Email: _______________________________________________________________________

Place of Birth
State*: _________________________ District*: _____________________________________

Village/Town*:_______________

Full Address
House/Door No.*:______________________ Village/Town*:____________________________

Tehsil / Taluka / Mandal / Thana*: _________________________________________________

Street/Area/Locality/Mohalla/Road*:_______________________________________________

Post Office*:________________________ Pin Code*: ___________________________

District*: _________________________

Relationship Name SurName Partnumber Serial Elector's

with of the Roll of Number in Photo
Applicant the the Part Identity
constituency Card (EPIC)
No.
Documents List:
(NOTE: 1.Total size of Upload Document should not exceed 3 MB.2. All Upload Documents should be in PDF Format Only)

1. Application Form*
2. Passport photo

Declaration

I am ordinarily resident at the address given in para II above since _________________

(DD/MM/YYYY)

My name have been included in the electoral roll for ____________ Constituency in
______
(OR)

Applicant’s Signature