FORM-6 (See Rules 19(1) and (26) ofthe Registration of Electors Rules, 1960) ELECTION COMMISSION OF INDIA. Applicat Acknowledgement ‘No $1305906N1301241200017 (obe filed by office) in Form for New Voters 0, ‘The Electoral Registration Ofcer, No. & Name of Assembly Constituency No, fe Name: Ramtek (OF No. £Name of Paliamentary Conctituency® No, (only fr Union Tertores not having Legislative Assembly) {submit application for inclusion of my name in the electoral ll for the above constituency. Name (1)(@) Name (In Oficial Language of State) First Name followed by Middle Name far arf ‘sumame (if any) ree (0) Name (In English in BLOCK LETTERS) Fist Name flloned by Mile Name GUDIVA MANISH ‘surname (if ny) YADAV Disclaimer: fname not ied in English, it willbe transiterated by software *(2\(a) Name and Surname (in official language of State) of any one ofthe eaves: or wite [] or Father or Mother or Husband Lege Guardian in case oforphan/Thira Gender (2) Name and surname (In English in BLOCK LETTERS) ofthe relative mentioned above MANISH YADAV wel ras (@) Mobile No.of Salf f available). siis]slsfolfofo]7lelo L Of elative mentioned at item No.2 [ l- 1 1 (4) Email 10 of Set avabable) o Ofreave menoned tem No.2 (5) Aadhaer Details l aK | Wels | LESLIE LL (cone wale muse | (abate of hmm Phe)’ Pel’ OleDede (2) st atest con of oct suporing ae ot ataced (anon o he folowing th docunent fr rf Clea ra aoe hese) 1] ft ceased compete Loca Bodnar Rega of Brit & Deas saan cat so) paved 4) ing eense of Indian Passport Ccerfiates of class x or Glass Xl ssued by CBSE/ICSE/ State EducatonBoards it contain Det of sith (W) any other Document for Proof of Date of sith (ne documents avalebe) (PL, specify)(ya) resent ordinary Realence (Ful Adress) House/Bullng/aparimert No, Gandhi Chewk Police Station KePas Tilt | stiecl/vea/Locally. Ward No 5 Gawlipura aS s7mrHigT pieced iso TensivTaluga/Mandal Kanban UT ‘Town/vilage Kenhan rt Post office Kanhan Sar Stole/UT Maharastra Distict Nagpur Pin Code 441404 (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 {| woterretectriciy/Gas connection Bil for that adéressatleast1 year) 2f] Aadnaarcard s[] Curent passbook of Nationlized‘Scheduled Bank/Post Office 4] tmtanPasspt 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 to the bes of my knowladge and belo. (tama chtizen of india and place of my birth is:- Town/Village Kanhan District: Nagpur ‘State/UT: Maharashtra (i) am ordinary a resident atthe adress mentioned at S.No.) in Form 6 since: 2017-08 (1am applying for inclusion in Electoral Rel forthe first 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 KANHAN ‘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. ‘Acknowledgement Number $1308006N1301241200017 DATE 13-01-2024 Received the aplication in Form 6 of Shi/Smt/Ms. Cudiya Manish Yadav far wea aca Applicant can refer the Acknowledgement No. to check the status of application ‘++ This ic @ computer generated document and doss not require signature **