9|R / FORM 6

[ B4R 13(1) W1 26 & ] / [See rules 13(1) and 26]

R|| 8V| R B|R H&B 4 HV WB /
Application for inclusion of name in electoral roll
P| H / To,
H3d|3| 9H|41 HH4|1| / The Electoral Registration Officer,
- H| PH| | H
- Assembly Constituency.
H[|d/Sir,
H1|H [ 4 H1| |H 343 | H 4| H3d|3| P| H T|HH 41 1 H3d|3| P| H T|HH 41
H P[|3| 4 H9 1 | d| "| [ :-
1. Hd4 4| 1 / Applicant's
details
Name : vikas Surname (if any) : patel
1 H1| 4| H /
Age as on 1st January 2013
4 / Years :
H[|| / Months : H " / Sex :
H7H 3, d 93| [ : / Date of Birth, if known
H7H 4| 1|
/ Place of Birth
0|H/414| (Village/Town) : teliyarganj
1|7 / State : S24
Surname (if any) : patel
39|H(d 4|( [ ) :
Name : vikas
|H :
II.
2.
P|H|73: 3 H| |P 1| 4| 1 (91| 93|) :
H4| / q|1 PE| : House / Door
"H| / H / 413| / H|[~H| / 1|s :
414| / "| :
s|4O|| : 9 4|s :
3[P|H/3|H4|/ HsH/|| : Tehsil /Taluka/Mandal/Thana :
3. Hd4 4 91|1 4 3 Pd1| 4 1 H4| |H | H H3d|3| P| H T|HH [ :
III. Details of member(s) of applicant's family already included in the current electoral roll of the Constituency:
HH|/ District
|H / Name
Hd4 P 13| /
Relationship with
applicant
| H 4| P| 4|
H|" / Part Number of the roll
of the Constituency
3P H|" H HH
PE| / Serial Number
of in that part
H3d|3| 4| 9||
9[| 4|s P. /
1.
2.
....................................................................................................................................................................................
....
Application ID : ECIS242622013Form61952 Hd4 4| 1P|d / Receipt for application

Received the application in Form-6 of Shri/Shrimati/Kumari vikas Address , ,
Date : 04-Jan-2014 Signature of the officer recceiving the application
on behalf of the Electoral Registration Officer
Application ID :
ECIS242622013Form61
mobile number :
e-mail address :
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 :
particulars of place of present ordinary residence (full address) :
street / area / locality / mohalla / road :
town / village :
post office : pin code :
elector's photo identity
card number
M
relationtype :
Husband
22/1
jondhwal teliyarganj
allahabad
teliyarganj
211004
sadar
HH|/ District
29
chhote lal patel F
manju patel M
9454110223
its.vikas17@gmail.com
01-07-1989
photo
262
1| :
Place :
3|1|O :
Date :
4|4 |#| 4| 1H / Details of action taken
(B|VB H 4 R|| 9H|41H N04|1| q|1| R1| H|4B|)
(To be filled by Electoral Registration Officer of the constituency)
| : 9P 43 4| H| 9P| 1 d 3| [ | |4| 413| [ H| HPc [ | HP [ H|3| [ | |P 413| [ 4 [
HPc [ | 3P4| Pc3| 91 |P [| 413|, H 93Hc HHH, 1950(1950 4| 43) 4| 4| H|1| 31 4 HH| d s|
[ 1
H3d|3| 9|| 9[| 4|s P. (d 9[H [ )
H|1| 41 4| 3|1|O / Electors photo Identity Card (if already
Hd4 4 [13|H1 | H" 4 T|
Signature or thumb impression of the applicant
|/|H3|/4 H|1| 4| Hd H3d|3| P| H T|HH 41 4 H9 9|H 6 1|4|1* / H1|4 3* 41 d|
"| [ 1
The application of Shri/Smt./Km. for inclusion of name in the electoral roll in Form 6 has been accepted*/recjected*.
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 Office (Seal of the Electoral Registration Officer)
number : date of issue :
(9|Fs HH N04|1| 4| 9H| 4|VHW, 9B|R N04|1|, 94 H4 N04|1|) / Remarks of Field Level
Officer (e.g. BLO, Designated Officer, Supervisory Officer.)
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)
04-01-2014
01-01-1900
IV. |4| / Declaration
H P4 q|1| |4| 413|/413| [

4 H1| H|4|1| 9 |P 4 HP|1 : / I hereby declare that to the best of my knowledge

and belief :-
(i) H H|13 4 |"14 [

1
(ii) H P|H|73: 343 91| 2 91 d 93 91 (3, H|[, 4 ) P 1[3| [

1
(iii) H 4P| H7 | H 4| H3d|3| P| H H9| |H T|HH 41 4 H9 Hd [| 4| [ 1
(iv) * H1| |H 9[H P P | 4P| H7 H|PH| | H 4| H3d|3| P| H T|HH [| [ 1
(i) I am a citizen of India.
(ii) I am ordinarily resident at the address given in para II above since (date, month, year)
(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
* H1| |H 1|7 4 | H 4| H3d|3| P| H T|HH [ H[| H 9[H +HO3 H3d|3| P| P 4| d| H|9 1
* 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 requested that the same may be deleted from that electoral roll.
91| 93| (P|H|73: |P 4| 9UH| 1|)
Full Address (Earlier place of ordinary residence) :