FORM 6

[See rules 13(1) and 26]

Application for inclusion of name in electoral roll

To The Electoral Registration Officer Assembly/ Parliamentary £Constituency. Sir, I request that my name be included in the electoral roll for the above Constituency. Particulars in support of my claim for inclusion in the electoral roll are given below:	SPACE FOR PASTING ONE RECENT PASSPORT SIZE PHOTOGRAPH (3.5 CM X 3.5 CM) SHOWING FRONTAL VIEW OF FULL FACE WITHIN THIS BOX
I. Applicant’s details	Name:	Surname (if any)
Age as on 1st January #	Years:	Months:	Sex (male/female/others):
Date of birth, if known:	Day:	Month:	Year:
Place of birth:	Village / Town:
District:	State:
*	Name:	Surname (if any):
II. Particulars of place of present ordinary Residence (Full address):
House/ Door number:
Street/ Area/Locality/ Mohalla/Road:
Town/ Village:
Post Office:	Pin Code:
Tehsil/ Taluka/ Mandal/ Thana:
District:
III. Details of member(s) of applicant’s family already included in the current electoral roll of the Constituency:
Name	Relationship with applicant	Part number of the roll of the Constituency	Serial number in that Part	Elector’s Photo Identity Card Number
1.
2.
3.

£ In case of Union territories having no Legislative Assembly and the State of Jammu & Kashmir.

# Please give the year i.e. 2007, 2008, etc.

* Strike out the inappropriate alternative

IV. Declaration

I hereby declare that to the best of my knowledge and belief : -

I am a citizen of India;

I am ordinarily resident at the address given in para II above since (date, month, year)

I have not applied for the inclusion of my name in the electoral roll for any other constituency;

*My name has not already been included in the electoral roll for this or any other assembly constituency;

Or

*My name may have been included in the electoral roll for Constituency in State in which I was ordinarily resident earlier at the address mentioned below and if so, I request that the same may be deleted from that electoral roll.

Full Address (Earlier Place of Ordinary Residence	Electors Photo Identity Card number (if already issued) Date of issue
Place:	Signature or thumb impression of the applicant
Date:
Please give your mobile number /E-mail I.D (Optional) /

A)	Note – Any person who makes a statement or declaration which is false and which he either knows or believes to be false or does not believe to be true, is punishable under Section 31 of the Representation of the People Act, 1950 (43 of 1950).

* Strike out the inappropriate alternative.

Details of action taken

(To be filled by Electoral Registration Officer of the constituency)

The application of

Shri/Smt./Km …………………………………………………………………............... for inclusion of name in the electoral roll in Form 6 has been accepted*/rejected*.

Detailed reasons for *acceptance [under or in pursuance of rule 18*/20*/26(4)]£ or* rejection [under or in pursuance of rule 17/20*/26(4)£]:

Place: Date	Signature of Electoral Registration Officer	(Seal of the Electoral Registration Officer)

£ During continuous updating after final publication of electoral roll.

* Strike out the inappropriate alternative.

Remarks of Field Level Officers (e.g BLO, Designated Officer, Supervisory Officer)

[This page should be thick enough so that it does not get mutilated /damaged in postal transit]

Intimation of action taken

(Section-II of the page is to be filled by Electoral Registration Officer of the constituency and to be posted to the applicant on the address as given by the applicant in Section-I)

____________________________________________________ First Fold _______________________________________________________

Section-I

The application in Form 6 of

**

** (Full address)

House/ Door number:

Street/ Area/Locality/Mohalla/Road:

Town/ Village:

Post Office:	Pin Code:

Tehsil/ Taluka/Mandal/ Thana:

District:

** To be filled in by the applicant.

________________________________________________ Second Fold _______________________________________________________

Section-II

has been—

accepted and the name of Shri/Shrimati/Kumari ……………………….. has been registered at Serial No ……… in Part No …………….of AC No …………………………………..

rejected for the reason ……..………………………………………………………………………

Date: ……………………	Electoral Registration Officer.

(Address)…………………….

………………………………

……………………………....

_________________________________________Perforation for detachment _____________________________________________________

Receipt for application

Received the application in Form 6 of **

**Address

Date: ………………………..

Signature of the officer receiving the application on behalf of the Electoral Registration Officer (Address) ……………………………

** To be filled in by the applicant.