FORM 6 [See rules 13(1) and 26] Application for inclusion of name in electoral roll To The Electoral Registration Officer, .............Assembly 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: I. Applicant's details Name Surname (if any) Age as on 1st January ..... # Years : Months : Sex (male/female) : Date of birth, if known: Day : Month : Year : Place of birth: Village/Town : District : State : * Father's/ Mother's/ Name Husband's Name Surname (if any) II. Particulars of place of ordinary residence (Full address): House / Door number : New. _______________ Old. _______________ Street/Area/Locality/Mohalla/Road : Town / Village : Post Office : Pin Code: Tehsil/Taluka/Mandal/Thana : District: # Please give the year i.e. 2003, 2004, etc. * Strike out the inappropriate alternative. P.T.O ........................(Perforation) ........................... Receipt for application Received the application in Form 6 of **Thiru/Thirumathi/Selvi....................... **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 ....(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 *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) number; ______________; date of issue ___________ Place : Date: Signature or thumb impression of 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 Thiru/Thirumathi/Selvi ........................... 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) £] : During continuous updating after final publication of electoral roll. Place : Signature of (Seal of the Electoral Date : Electoral Registration Officer Registration Officer) £ * Strike out the inappropriate alternative.
