Form 6

“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: Name Surname (if any)

I. Applicant’s details Age as on st 1 January…………..# Date of Birth, if known Place of Birth:

* Father’s Mother’s Husband’s

II.

Years:

Months:

Sex (male/female):

Day: Village/Town: District : Name

Month:

Year: State: Surname (if any)

Name

Particulars of place of ordinary residence (Full address):

House/Door number: Street/Area/Locality/Mohalla/Road: Town/Village: Post Office:

Pin Code

Tehsil/Taluka/Mandal/Thana: District: £

In case of Union Territories having no Legislative Assembly and the State of Jammu and Kashmir. # Please give the year i.e. 2003, 2004 etc. * Strike out the inappropriate alternative.

……..……………………………………………..(Perforation)……………………………………………………………………

Receipt for application Received the application in From 6 of ** Shri/Shrimati/Kumari………………………………………………….. ** Address………………………………………………………………………………………………………………

Date:………….

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

** To be filled in by the applicant.

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.

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 …………….. (data, 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 * 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 (if issued) ………………: date of issue…………….

Place:

Date:

number:

Signature or thumb impression of the claimant

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)] *rejection [under or in pursuance of rule 17*/20*/ 26(4)£ ]:

Place: Date: £

Signature of Electoral Registration Officer

During continuous updating after final publication of electoral roll.

* Strike out the inappropriate alternative.

or

(Seal of the Electoral Registration Officer)

FORM ID

ECI-EPIC-001A

Election Commission of India Form for submission of photograph (optional) along with Form 6 / 8 / 8A Name of State / Union Territory No. & Name of the Constituency Details of Applicant as given in Form 6 / 8 / 8A 1. Name of Applicant:

Paste recent passport size Photograph (3.5cm x 3.5cm) Do not sign on this Photo

2. Father / Mother / Husband’s Name: 3. Particulars of place of ordinary residence (full address) House/Door number: Street/Areal/Locality/Mohalla/Road: Town/village: Post Office: Tehsil/Taluka/Mandal/Thana: District

Pin Code

I am submitting two copies of my recent passport size photograph. One pasted on right side top corner of Form 6 / Form 8 / Form 8A with my signature/ T.I affixed across the photograph. The other photograph has been pasted on this application for the purpose of preparation of Elector Photo Identity Card (EPIC). I am aware that no EPIC will be issued using this photograph if my claim for inclusion in the electoral roll in Form 6 or for transposition of entry in Form 8A is not accepted and the photographs will not be returned to me.

OR This photograph may be used to replace wrong photograph appearing in the photo electoral roll against my name as per application for correction made in Form 8. Place: Date:

Signature / T.I. of applicant Note : Please enclose photocopy of some document like Passport, Driving Licence, Arms Licence etc. showing your photograph and same address as in the application, if available. Show original for verification at the time of submission of the application and also at the time of field verification or hearing, if required. (for official use only)

CERTIFIED that I, …………………………………., S/o. ……………………………………………….……………. …………………………………………………………………………………………............................................. (designation of verifying/attesting officer) have verified the authenticity of the applicant’s photograph with original passport / driving licence / arms licence / others (specify name of document and get one photocopy if not already attached) or on the basis of the statement of Shri / Smt._________________________(name of the person) supporting the authenticity of the photograph, whose name is included in the electoral roll.

Signature of official