FORM 6
Application for inclusion of name in electoral roll
   Assembly Constituency :                                                        
   Part No :
  I. Applicant's Details :
   Name :
   Age as on 1st January of (EnterYear):      
   Years :
   Months :
   Sex :
   Date of Birth ,if Known (mm/dd/yyyy):
   Place of birth Village/Town :           
   District :
   State :
   Father / Husband's name :
  II. Particulars of place of ordinary residence ( Full address) :
   House / Door number :
   Street / Mohalla / Road :
   Town / Village :
   Post Office :
   Tehsil / Taluka / Thana :
   Pin Code :
   District :
  III. Details of member(s) of applicant's family already included in the current electoral roll of the Constituency :
Note:Press Add More button after adding each member details.
   Select totall no of members already included in roll :    
   Relative Name :
   Relationship with applicant :    
   Serial number in that Part :
   EPIC No :  
 IV. Declaration :
       I hereby declare that to the best of my knowledge and belief :-
 ( i )     I am a citizen of India.
 ( ii )    I am ordinarily resident at the address given in para II above since (mm/dd/yyyy) : --
 ( iii )   I have not applied for the inclusion of my name in the electoral roll for any other constituency.
 ( iv )   My name has not already been included in the electoral roll for this or any other assembly constituency.
Or
     ( i )  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 the same may be deleted from that electoral roll.
           
    Full Address (Earlier Place of ordinary residence ) : 
    EPIC No (if Issued) :  
    Date of Issue : (mm/dd/yyyy)--  
 
    Place :   
    Date (mm/dd/yyyy) :   --  
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