12/27/22, 2:30 PM form6

form6
                                                        ELECTION COMMISSION OF INDIA
                                                                    FORM-6
                                                                                                                                     (See Rules 13(1) and 26)

                                                                                        Application form for New Voters

To, The Electoral Registration Officer,
Maharashtra Savner
 Assembly / Parliamentary Consitituency
Personal Details
First name followed by Middle
Name
Rohini Sadashiv रोहिणी सदाशिव

Surname(if any) Nimje निमजे

Father ☑      Mother ☐      Husband ☐      Wife ☐      Legal Guardian in case of orphan/Guru in
Type of Relation
case of Third Gender ☐
Name and surname of of any one of
the relatives
Sadashiv    Nimje सदाशिव    निमजे

Mobile No. of Self (if available) 9561497628 Relative ☐

Email id of Self(If available) rifoyvfesispbrswos@tmmbt.net Relative ☐
Aadhaar Number
Gender Male ☐      Female ☑      Third Gender ☐
Date of Birth (in DD/MM/YYYY format) 14/08/2002
Document for proof of Date of Birth Aadhaar Card
House/Building/Apartment
Present Ordinary Residence
No.
Ward No 2 वार्ड नं 2

Street/Area/Locality/Mohalla/Road At Dhapewada मू. धापेवाडा

Town/Village Po. Dhapewada(bu) पो. धापेवाडा (बू)
Post Office Dhapewada धापेवाडा Pin Code 441501
Tehsil/Taluqa/Mandal Kalmeshwar कलमेश्वर
District Nagpur State/UT Maharashtra
Proof of Residence Aadhaar Card
Category of disability if any(Optional)
Percentage
Locomotive ☐    Visual ☐    Deaf & dumb ☐   
Disability (if any) of Certificate Attached ☐
Other _________ disability
Name of family member
Relationship with Father ☐      Mother ☐      Husband ☐      Wife ☐      Legal Guardian in case of orphan/Guru in
applicant case of Third Gender ☐
His/Her Epic No.
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 Nagpur District Nagpur State Maharashtra
(ii) I am ordinarily resident at the address mentioned at Sr. No. 8(a) in Form 6 since 27/12/2022 .
(iii)I am applying for inclusion in Electoral Roll for the first time and my name is not included in any Assembly

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