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 :-

1.Applicant’s

details

1. Title :

2.  First & middle name :

3. Last name :

4. Age on 1^st January…...

5. Years :

6. Months :

7. Sex(male/female) :

Date of birth, if known:

8. Day :

9. Month :

10. Year :

Place of birth:

11. Village/Town :

12. District :

13. State :

II. (a) Details of relation of applicant (Father/

Mother/Husband)

14. Title

15. First & middle name :

16. Last name :

(b) Relationship with applicant   Father/Mother/Husband :

III. Particulars of place of ordinary residence (Full address) :

17. House/Door number :

18. Street/Mohalla/Road/Gali :

19. Area/Locality :

20. Town/Village :

21. Post Office :

22. Pin Code:

23. Police Station :

24. Tehsil/Taluka :

25. Block/Mandal(for village) :

26. District :

IV. Period of continuous residence at the above mentioned address on the date of application.

27. Years :

28. Months :

V.  Details of local Body and Ward in which the place of ordinary residence al III above is included :

29.(a) Notified Area Committee/Municipality/Municipal Corporation/cantonment Board 9(for urban area)

(b) Gram Panchayet (for rural area)

30. Ward number of the above local Body :

VI. Reference in  support of claim, if any [ Details of member(s) of applicant’s family included in the current electoral roll of the constituency] :

Name (s)

Relationship with applicant

Part number of the roll of the Constituency

Serial number

in the part

1

2

3

VII.  Details of Elector’s Photo Identity Card, if issued, in this or any other Constituency

31. Elector’s Photo identity Card number :

32. Date of issue :

33. Constituency (Assembly/Parliamentary Constituency) Name :

VIII. Declaration

         I hereby declare that – (I) I am a cititzen of India (ii)  I have not applied for the  inclusion  of my name in the electoral roll for any other Constituency; (iii) (a)  My name has not been previously included in the electoral roll for this or in any other Assembly/ parliamentary Constituency; or (b) I was an ordinary resident earlier at the address mentioned below an my name is included/might have been included in the relevant part of the electoral roll for:

34. Assembly/Parliamentary Constituency

Number:

Name:

35. State/Union territory:

36. Part number:

37. Serial No.

38. House/Door number:

39. Street/Mohalla/Road/Gali:

40. Area/Locality:

41. Town/Village:

42. Post Office:

43. Pin Code:

44. Police Station:

45. Tehasil/Taluka:

46. Block/Mandal

47. District:

I request that my name, so included/if so included may be deleted from that electoral roll.

(iv) . The facts & particulars mentioned above are true to the best of my knowledge and  belief.

Place:

Date:

…………………………………………………………...        Signature or thumb impression of claimant

I am  submitting the application to the Electoral Registration Officer  through

(i)    Shri/Smt/Km. (full name & address)           or  (ii)    in person / or (iii) by post

 … …………………………………………………………… Signature  or thumb impression of claimant

Note -  Any person who makes a statement of 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

Details of action taken

(to be  filled by electoral registration Officer of the constituency)

Revision identity

Constituency number and name

The application of Shri /Smt./Km……………………… for inclusion of name in the electoral roll in Form 6 has been accepted/rejected.

Accepted :

a)

Under rule 18/rule 20 and name

of the elector is included in the 

electoral roll of the Constituency finally published on …………. After Intensive/Summary/Special revision

Serial number allotted

In part number

Or b)

Under sub-rule (4) of rule 26 and name of the elector is included in the electoral roll of the constituency

Rejected :

Rejected, under rule 17/rule 20/26(4)

Detailed reasons for acceptance [under rule  18/20/26 (4)] or rejection [under rule 17/20/26(40)].

Details of acknowledgement particulars indicated in Form 9

( To be filled by Officer receiving the application )

Details of acknowledgement receipt issued to the applicant.

Receipt number :

Signature of Officer

Receiving the application

Date of receipt :

Remarks, if any, of the Officer receiving the application:

Application received by:

Name of Officer:

Designation:

Personal identity number:

(as allotted by the District Election

Officer/Electoral Registration Officer

 for the purpose of revision of rolls)

Designated location identity

(where the Application has been received)

Serial No. of the Form in the list (Form 9)

Date of the list

(Form 9)