FORM-6 (See les 13(1) ad (2 ofthe Regiaton of lets Rules, 1960) ELECTION COMMISSION OF INDIA Application Form for New Voters Acknowiedgement No soer7ao6nt401241200002 (Tobe filed by ofice) 7? te Electoral Regstiation Ofc, _ No. & Name of Assembly Constituency We Wl Name: Jalalpore OF No. £Name of Palamertary Consutuency@® No F (@onlfortnion Temtares not having Leisatve Assembly) — | submtappieaton fr intucion of my name nthe electoral ol forthe above consttuency. Name: (06) Nomen ofc Language of at) Fist Name olone by MidleName alee get Surname (fay) a8 (QName (in English in LOCK LETTERS) Firs Name followed by Middle Name SHAHJAD HUSSAIN — Suing fay) SHAK Disclaimer: fname nt ile in English willbe wansierated by software, *(2)(a) Name and Surname (nofeial language of State) of anyone oftherelatves- father [~] or Moter[—] or tusband or fe or Legal Guardian in case of orphanThird Gender (2) Name and surame in English in BLOCK LETTERS) oftherelave mentioned above HAFIZULLAH SHAH oleyetis aus (@) Mobile No.of st (aval). eloyzlelileole (Of eltive mentioned at ter No.2 el L-] @)Email0 of se aveilble) or Of eltive mentioned at tem No.2 nen GOEL (Gender MALE FEMALE ‘THIRD GENDER Coa or re CPE)’ be): Pee (0) sat atsted copy of document supporting age proof attached (anyone of the flowing) (@ Document for Proof of vet of ith (Anyone ofthese) 11] Bithcertfcate issued by Competent Local Bod/Muricipal Authority Registrar of ths & Deaths af] Asda care PAN card 4[] Diving License si] camicates of class Xr class x ssedby COSECSE State Educatondoards itcontandateofBiah 6 Indian Passport Any Other Document for Poot of Dat of ith: (Fro documents avalible) (Specify)(@) le) Preset Ordinary Residence (Ful Adee) Home/Buling/Aporment Ne. 423.423 SucevAcatocaty, MAROUIBAZAR Mie oe “elyTalagartancal JALALPORE Ne? Towrvitage maou sald Post offes MAROU AAA sxste/UT Oujrat Disick Nasa FinCode 396196 (©) Settateated copy of dress proot eter inthe name of applicant or any one of paente/spouse/adu chil, akeadyenrlled as elector at he same adereas arach anyone ofthe) (@ Document or proof of residence“ al_v | wetevetectricty/aas connection Bilfor thet adress(ateast 1 year) 2 Aadhaat Card a ‘Curent passbook of Naionaizd/Scheduled Bark/PostOfice {| nfanPassoe 5) ] Revenue Departments Land Owning records including Kisan Babi [| Pevstrret soc veedncasoteran) 7) Ragitared Sale Dsssineaee of enn house) (0) Any ter oacument for Proof of ealenee na document vas) (Spee) (9)categary of sisabity, any (Options) tesmone [] vst) cere Dumb I any other (ive desertion Percentage of isabity eee stacbsicthesspopratebos) Yes no [|] (o)The details of my family member steady included inthe electoral al st curent addtess with whom Icuretly reside are 9 under "Name of famly merter SHAFIULLAM SHAK Relationship wih appicant Legal Guardian incase of His/her PIC no. IMQQS76478 orphanyGuruin can of Third Gender DECLARATION: HEREBY DECLARE that tote best of my knowledge and belef= (@) Lama étizen of india and place of my birth is- Town/Village NAVSARI District Neves ‘State(UT Gujarat, (Lam ondinatiy resident atthe adress mentioned at Sr.No. a) in Form 6 sine: 2004-08 (iy 1am applying for ineusion in Electra Rel fr the fret ie and my name isnot included in ny Astembly Consutuency/ Parlamentary Conetiuency. (@) 1 dont possess any ofthe documents of age prea. Therefore, rhave enclosed: (Name ofthe document in supper ef age proof (stke of, ifnetaplleable) (9) Lam aware that making the above ctaement or declaration elation ethic application which fale and which know or believe tobe face or donot belive tobe tue, 's punishable under Section 31 of Representation of the People Act, 1950 (43 of 1950) with imprisonment fr aterm which may extend to one year or with fine or with bath, Dare 14-01-2028 ‘AccessibtyInsruetions Inthe light of provisions af Rights of Persons with Disabilities Aet 2016 and Right of Persons wth Disables Rules, 2017, In ease of persons with intellectual disability, autism, cerebral palsy and multiple disabilities et. signature or left hand thumb impression of person with disability, or signature or left hand ‘thumb impression of his/her legal guaran wil be required Nate: [in ease of married female applicant name of Husband may preferably be mentioned =| Submission of ef attested copy of document will ensure speedy daivery of services. | mease none of the documents is aval, eld verification Is musts fr example categoryike homeless indian zens who are otherwise elgibleto Become: clocters but do not possecs any documentary proof ferdnary residence, Electoral Registration Oficer call designate an officer for fil verification ‘Aclnnaleigemestibecin Ackrontdgement uber S0617406N1 401241200002 are 012028 Reseed he applestion in Form Saf hase SHahkD HUSSAIN Shak aw geet Lappcant can refer the Ackrowiedgemert No. to check he status of apleston] ‘8 This ls a computer generated document and does not require signature *¥*