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ANNEXURE IV(For Form-6)

DECLARATIONBY STUDENTS LIVING IN SPACE FOR PASTING

ONE RECENT
HOSTELS/NIE S SES/ELSEWHERE PASSPORT SIZE
COLOUR PHOTOGRAPH
(TO BE ATTACHEDWTTTITORM 6) (3.5 CM X 3.5 CM)
SHOWING FRONTAL

I, ...... ..............(NAME IN BLOCK LETTERS),

VIEW OF FULL FACE
WITHIN THIS BOX
: son/daughter of

address of native place), hereby declare that :-.--

(a) I am a bonifide student of ...... ......( name of
the institution) and pursuing .....(details of the course)
from .(month).. ...(year)
to..............(month) ......(year)
*(U) t am presently residing
at -
(i). (if
residing in hostel/mess, mention Room No./BlockNo./ BlockName, etc. of the
hostel/mess).
OR
(ii) (if residingelsewhere
dft '|rrrlrv
postal address of the place of stay outside ".iri,-rtJtii'"vrJ!
the hostel/mess).

(c) * I want.to be registered in the.electoral roll/retain my registration in the electoral roll of

my natlve place at my above-mentioned residential addre5s wTth my parents/guardian.
OR

*I want to be registered in the electoral roll of the constituency where

I am presently residing .

[. I am 4ware that.registration in the eleqtoral roll of more than one constituencv or more
man.once.ln a constltue-ncy_lq netlermlttqd_lndgq the el_ection _law and am also atiarc of the
penal provisions of Sec. 3l i,f the R.P.Aci; I950;w[icf ieadi-ili'bl6wil'--
persln makes in clnnectiln with (o)^the preparotion, reyision or correction of an electoral roll, or (b)
.','lf !ny,
llte inclusion or exclusion of any entry.in or froy'on.'electoral roll, a statement or declaration inwriting *lrici {s
"to
fapg gnd which he either htowi or lelieves be false or does not believe to be true, ni sltitt ti pini,isiii[e
with imprisonment lor a term which may exteid to one year, or with line, or with both.

Place: (signature of the student)

Date :
It is certified that the information given in the declaration (a) above and the x
photograph have been verified from the records of the institution and aie found to be correct.
Place:
Date:

Signature and seal ofthe

Head Master/PrincinalR