AcknowdgrentNuber: -$2509008W0512231200047 Subission Date 05-12-2023 FORM 8 } (See Rules 13(3) and (26) of the Registration of FORMNO___ " OG Electors Rules, 1960) or ELECTION COMMISSION OF INDIA (eosin Voter Application Form for Shifting of Residence/Correction of Entries in Existing Electoral Roll J Replacement of EPIC / Marking of PwD Te ‘The letra Regtstonofice, Ni, and tame of Assay Constiuncy no. [0 Name Ranaghat Dakshin (Ot No and Nae of Paliamentry Constivency No. Name. - (@ ‘en forunon Tetees not hating legate assenb) — (Mamet the appican- adison Mondal EPICN. _NEv2369205 AadhaarDotale- Peastktteapoprte bax) [2] sara sb thee Plel« (2) [J ‘tamrtat enshmy Aina namritha theron cleat) ep bb PP PEt Mobile No. of Father’Mother/Any other relative (tf available) C | fall of a) Email of FatheMathe/an other lateitaeicble) malicktelecom77@amaiLcom (QW) submit application for (Tick any one of the following), 1. [D] cntingattesereten 2) weston stenresin ensign lon 2. [] new otReteaen Ee wit concen (0) a | quest for marking as Person wt Diseity 1 Applian fr Shifting of Residence Ihave shifted my residence ed request tht my name maybe delete rom te previous adess and shied tothe curentadess mentone below request he enscemet EPIC may be issued to me det change in my adress. hereby retum my od EPIC Present Ordinary | House/Building/Apartment No. NOO71 | 071 ‘Street/Area/Localty/ Mohalla/Road ‘OURISAILHIGH SCHOOL ROAD! | ecdercerot | Touvvlage | GOURGALPURBA CTAB Arte gr cas sc) Pree | 7aea8 Fem es | GANGSARARLFERGRaM | ET TT oat [oi TehsiTaganiand | MAIMERGRAM CRE Sate | WestBowl ‘Selatested copy of ares proof eter nthe name of applicator anyonecf th patents spousradut child If ready enol with as eetorat the same adios (bitch any one ofthe docurents mentioned below *- 1.) watretetyss erat ies cas you) oO 3 2. [) camannsebcokornetnaaestedded senrost oe 4) indonesia S|) evenuDesutent Lang ovina zinc eo Soh 6. | enters ertesse bee nos teen 7) esstedsolecestn cas ctean eus) ny Other-(P Speiy]~ RATION CARD2. plication for Correction of Enisin Eisting letra Roll ease covet following detain eto ROUEPC (Maximum of 4ertsspartiuls can ba coreste) (Puttick anbsa aororeteboxbeow) r 7 SPACE FOR FASTING Copy of stated Documentary Poon support of tam to bested one Recenr asspo=t a TF +] same 2) onder 8 [) pesiage SSZEUNSGNED COLOR 4] pettooryp s [) pactonnane «assess aoToGRARH (45M : — 850M sHOWNG r Mabie number 8 [| Phoo FRONTAL VEWOF FULL AGE WaT WATE rectpericuls inthe ert be coreted eo under BACKGROUND ONLY IF PHOTO TOBE CHANSED) pT 6 J} ‘Name of Dcurart in support f above am attachad b a i TT | request that replacement EPIC may be sued tome do change my personal deals hereby return my od EPC ‘3. Application for Isue of Replacement EPIC without earecon Mequestthat replacement EPIC may be leauad tame a my ong EPIC - (tack inappropiate box) 1 lost 2 [] pestojed due to reason beyendcotal ike foods, fre, other atl ses ete 3 (L] matted etey tun my mutated OISEPIC (OR) have attached copy of FR/Plce repr for lst EPIC lundertaketretunthe ate EPIC esued ome the sae recovered attr stage “Applicaton for Marking Person wih Disabiaty Categry af sabi (Tickthe appropiate bor for catagory of sai) [J toxamne Vina vests buno | anya (Gn éeeten Percentage of disability: * Certificate stteched (Tick the appropriate box) ] Yes No vecuaRaTON | HEREBY DECLARE that to the best of my krone and belief that | am ciizen of India and | am aware that making a statement or declaration whch is false and wich | know or believe tobe false or do not believe to be tut, is punishable under Section 31 of Representation ofthe People Ack.1950 (49 of 1950) with imprisonment for a term which may extend to one year or wih fine or with both. Date: 05-12-2028 Place: OOURISAIL PURBA Accession ne ight of poisons of ig of Parsons wth Disabil Act 216 and Righsof Pasone wih Disables Rule, 2017 cae of persons ith nllactul sabi aus cerebralpesy and mull dailies signature oft hand tun impression of parson with silty oof signatiueo than thu impression of isher legal quran wile equred ~ submission of slatted copy of mentoned documents wl ensre sped deveryofserce. KK - ‘Acknowledgementnecep fr aplication Kx OK Acknowiedgement Number» $2508008H0512231200087 Date 05-12:2028 Recsvedthe aplistion nForm of StrSrt./Ms, Aion Mend Nama/Sgrature of ER0/AEROVBLO ‘1 This Is 2 computer generated document and does not requte slnatre =