Election Commission of India Form for submission of Photograph (optional) for Elector Photo Identity Card & Photo Electoral Roll. Form ID ECI-EPIC-001B No. & Name of Constituency Part No. No. & Name of Section: ** Particulars of elector as per finally published Electoral Roll, 200__ Sl. No. House No. Address Name Relationship Relation's Name Sex Age EPIC No. Minor corrections in spellings of name & relation's name EPIC No. may be indicated clearly by hand by the elector. In case the pre-printed House No. & Address is correct but inadequate then the full postal address should be written below: - House / Door No. Street/ Area/ Locality/ Mohalla/ Road: Town/ Village: Tehsil/Taluka/ Mandal/Thana: Post Office: Pin Code: District: In case any particular has been wrongly printed then application should also be filed for rectification of the defect in the electoral roll. If either your name or relation's name or age or sex has been wrongly printed then From 8 should be filled up. In case you have changed your place of residence within the constituency the fill up Form 8A along with this Form Two passport size photographs are pasted in the space provided - one Signed across and other unsigned - at my own cost for preparation of EPIC & photo electoral roll. An attested photocopy of a photo-bearing Identification document is also enclosed. Place: Date: Signature of applicant [Note: Please enclose attested photocopy of any of the following photo bearing documents for verification of the photograph and date of birth. In case the document is self-attested, then show the original at the time of submission of the form in person - 1. In support of photograph - Passport, Diving License, PAN Card, Service ID Card issued to employees by State/Central Govt., P.S.U., Registered Properly Deeds, Public Ltd. Co., Passbook with photograph issued by Public Sector Bank/ Post Office, Students Identity Card issued by recognized Educational Institution, SC/ST/OBC Certificate, Pension Document, Railway Identification Cards Freedom Fighter ID Card, Arms License, Certificate of Physical handicap, ID Card issued to Bidi Workers byMinistry of Labour, Job Cards issued under NREGP, Electors photo Identity Card (EPIC) issued, if any ] 2. Proof of Date of Birth - In case date is not indicated in the document attached in support of photograph then Birth certificate issued by a Municipal Authority or district office of the Registrar of Births & Deaths or Certificate issued by Educational Board / University in which date of birth is printed should be attached. NB: ** Preprinted from database. (To be printed bilingually in the language in which EPIC is printed) Affix one passport size (3.5 cm x 3.5 cm) coloured photo here. (Do not put your signature on this photo) Affix one passport size (3.5 cm x 3.5 cm) coloured photo here. (This photo should be signed across, i.e. part of the signature on the photo and part on the form) My Date of birth is D D M M Y Y Y Y
