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conse ater -SO4OENIENE31 00004 Submision 10-08-2005 FORM § } (rae 859 agit Eee pull q O ules, 1960) YG ELECTION COMMISSION OF INDIA HN Voter Application Form for Shifting of Residence/Correction of Entries in Existing Electoral Roll / Replacement of EPIC / Marking of Pw ia ‘ThefecalRegraten fox, No ateameo! ss Consiney wo [08 Name BtaagarEast rNo and Name of Premartay Cantnerey No Nae (goer Unters ota eae Assent) Cuesta RON OH rene, von Ando Wak: Persea) 0 Exum Chobe bbb bbb tele 0 {amoot alta anh ny ahaa Naber because dot ae Atha Nber at 0 +TrIs obi o.of Fate Metheny otra eae) [ I Enalléof Sea) gunbinraréggmalcem aldo Fate Methny or ate i al) (Ws apletin or Tekaryenctie eon) 1 2] saitingot esi 0) Caretnol nis in bsg Beta a Iss of Recor EPI whut coestn a) 4 equa: arkng as Poson wth ity 1. Appear Siting Restece "hatha een ad us hat my rameray be ded ome revs aes an shed the carer aes mertned eo eq that elcome EC may else ome eo change ln crs hay tummy od Fret Oey |Help Na maTWOTI TONS Steet ay Maas DALARAN PARK RECA TENE estes ul hed ngredl SE eres ae ad ees) Tennis | BANCART LER Fete eARUGAR MeO AN | to TetTavaliia | BHAMNGAR| RR Devs | Bana sult et Satatests spy fetes rou ate ntenane cl plato annette apse ci ety le wh ase esaneaces (stacy oe ote dorunens eines bow 1 ters i oa aces ant eat) 2 2) sada 4 ure passbook of Nal Scot Banh Ps oe 4 Insan Passat 5 evenvDeparnets an Curing crs nn Kn Bt ‘ eget Rr ate Dee neste feat) Peis Sale Dean caso nou) yer PL Spec {Appt or Crastn of xin in xisig Etro Peas cect my olown alsin Ber PERC: (rir of enters cat be caret) (Putarck v xb appt trbeton) SPACE FRFASTNG ONE notteeetnant ee sap eet ayers + hie 2) sneer 3] oatitge Unsce coL0R © org 5 eee © OD vets arose users io = cap stwn OAL 1 [7] Wes § Poo ves oFFULFACE MT HTEEADGRONO ONLY ‘acre tila becoce east Foro TORE MND) ane Donmentin pout ove atached & ‘ rush scent EPC ray be sued mecue tach pond al Usb eu myo EPC 3. pation for sue of Relaemen EPIC wit earetice request tata repacoent EPG mae eset mea my orgal EPCs (Puatekinepsopatebor) 1 los 2 Desay eto ressn bon antl foots ohe natal sate. 4 Mutat Ines my muse ag PC (OR ave tached con of FRU repr lost EPC lundersetarean te est EPC sue ie sae seco alte sage “Apt er Marking Pron wit Dsbity ear of ait (Ti te proiteboxareatepr of dab) Loonie sua Det ou fy oe Ge Sesrtin Peerage of sity x Cercle stated (Tekh apposite) vs No DECLARATION | HEREBY DECLARE tat tote best of my Anowlge and belt tht | am a cien of Ida and | an avare that making 2 stent or delraton which i abe and wich | knew or alert be fle or do nt belo to be i,k pnihable under Secon 31 of Reena of the People Act 1950 (3 of 180) wth inprtoomet fr term wich may etd to ‘one year oF with fe owt bo pe) ace AYNAGAR Aecessilty scons: eg of poss of gts ol Passos wth Dati ct 206 and Rights of Persons hibits Res 207 incase pesos wh neal us ceva ely and util dss ee, spur orlet aun neesonefpeson wth sain ore ipere ore hr ur essen othe gel guaran bere * Submission of se atest op mentned coun wilensie sped eyo seve, x oe ® ‘cknowleigenet cit fo apa KX Acnouegen Nue $61040Wr0823100004 De: 1-06-2008 Received te aplcson nfo of ShiSat/Ns HRENBAA GANDA NaalSprare of FOIAEROLO ‘This a coeper gente document and des not require sigue **

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