FORM-6 (See Rules 13(1) and (26 ofthe Registration of Electors Rules, 1960) ELECTION COMMISSION OF INDIA. Applicat Acknowledgement ‘No $1305806N1301241200042 (obe filed by office) in Form for New Voters 0, ‘The Electoral Registration Ofcer, No. & Name of Assembly Constituency No, 2 Nome: Karthi (OF No. £Name of Paliamentary Conctituency® No, Name (only fr Union Tertores not having Legislative Assembly) {submit application for inclusion of my name in the electoral ll for the above constituency. (1)(@) Name (In Oficial Language of State) Fist Name followed by Mile Neme iar Fi ‘surname (if any) ete (0) Name (In English in BLOCK LETTERS) Fst Name flloned by Mile Name KANTA MILIND ‘Surname (if ny) RAMTEKE Disclaimer: fname not ied in English, it wil be transiterated by software *(2\(a) Name and Surname (in official language of State) of any one ofthe eaves: Father or Mother or Husband or wite [] or Lege Guardian in case oforphan/Thira Gender (2)) Name and surname (In English in BLOCK LETTERS) ofthe relative mentioned above MILIND RAMTEKE fife (@) Mobile No.of Salf f available). 7yef2i1fslefe loaf. Of elative mentioned at item No.2 [ (4) Email 10 of Set avabable) or Of relative mentioned at item No. 2 (9) anda: betas Eee] (6 cender uae [] reams TS] tances] (yaoate of itn (asm fel*|]’ [elv]’ [+ [ofr]e L lL (Sef attested copy of document supporting age proof attached (anyone ofthe following) (Document for Proc of Date af Birth "(Anyone of hese) 11] ith certificate issued by Competent Local Body/Municpal Authority Registrar of Births & Deaths 20) adnaar card 8 PAN Gard 4l Diving License 5 Incian Passport Ccerfiates of class x or Glass Xl ssued by CBSE/ICSE/ State EducatonBoards it contain Det of sith (W Any other Document for roof of Date of Birth (ine documents avaible (PL, spect.(ya) resent ordinary Realence (Ful Adress) House/Bullaing/Apartment No. ABDULA SHAH DARGA KE PAS araqrer=arg | slieel/Avea/Locelly, CHITTRANJAN NAGAR. Fraréart =r feats TehsivTaluga/Ntandal KAMPTEE TE ‘Town/vilage KAMPTEE TTT Post office KAMPTEE TTT Stole/UT Maharastra Distict Nagpur Pin Code 441002 (8) Setfattested copy of adress prof ether inthe name of applicant or any ane of parens/spouse/adult child, already nwoled as elector at the same adess (attach anyone of them) ( Document for proof of residence Wioter/Slectrcity/Gas connection Bil for that addressatleast 1 year) 2f] Aadnaarcard [)_curent passbook of Nationlized‘Scheduled Bank/Post Office {| tnianrassot 5 Revenue Department's Land Owning records including Kisan Babi Registered Ret Lease Deedinease of tena) Registered Sale Deed(incase of own house) (Any other Document for Proof of residence: no document i availabe (Pl, Speci. (oyeategory of sisi, if any (Optional) Locomotive | Deata Dumb It anyother (Give desertion): Percentage of disbilty Js certificate attached (Tick the appropiate box) Yes No (10)THe detail of my family member sendy included in the electra ol at cutent address with whom I cutenlresde are as under Name of family member: Relationship wth applicant Hisyher EPIC no. DECLARATION- | HEREBY DECLARE that tthe bes of my knowledge and bel (tama ctizen of india and place of my birth is:- Town/Village KAMPTEE District: Nagpur ‘State/UT: Maharashtra (yam ordinarly a resident atthe adress mentioned at S.No.) In Form 6 since: 1974-02 (1am applying for inclusion in Electoral Rel forthe fist time and my name is not included in any Assembly Constituency/ Parlamentary Constituency. (tv) dot possess any a the documents of age proof. Therefore, have enclosed: (Name of the document) in suppor of age prof (strike af, not applicable). (o) 1am aware that makin the above statement or declaration in relation to this application which is false and which know or belive tobe false or do not belive to be ‘tue, s punishable under Section 31 of Representation ofthe People Ac, 1950 (43 of 1950) with imprisonment for aterm which may extend te one year or with fine or with both, DaTE:12-01-2024 PLACE KAMPTEE ‘Accessibilty Instructions In the light of provisions of Rights of Persons with Disabillies Act 2016 and Rights of Persons with Disabilities Rules, 2017, in case of persons with intellectual disability autism, cerebral palsy and multiple disabilities et, signature or lft hand thumb impression of person with dsabilily, or signature or left hand thum’ impression of hisiher legal guardian wil be requied. Nols: = [Incase of marred female applicant, name of Husband may preferably be mentioned. ‘Submission of sell-atesied copy of document wll ensure speedy delivery of services. = [Incase none of the documents is available, eld verification Is must As for example, category lke homeless Indian clizens who are otherwise eligible to become lectors but do not possess any documentary proof of ardinary residence Electoral Registration Oficer shall designate an office for ld veifiaton. ‘Acknoledoementeeseint ‘Acknowledgement Number §1308806N1301241200042 DATE 13-01-2024 Received the application in Form 6 of Shri/Smt/Ms. KANTA MILIND RAMTEKE ot fee Hes Applicant can refer the Acknowledgement No. to check the status of application ‘++ This ic @ computer generated document and doss not require signature **