Hkkjr fuokZpu vk;ksx

ELECTION COMMISSION OF INDIA QkeZ&6 (FORM-6)

[fuokZpd jftLVªhdj.k fu;e 1960 dk fu;e 13¼1½ vkSj 26 nsf[k,] (See Rules 13(1) and 26) of Registration of Electors Rule-1960

vfHkLohdfr la[;k------------------------ Acknowledgement No.____________

¼dk;kZy; n~okjk Hkjk tk,xk½ (To be filled by office) igyh ckj ernkrk ;k fdlh ,d fuokZpu&{ks= ls fdlh vU; ,d fuokZpu&{ks= esa LFkkukarj.k ds dkj.k fuokZpd ukekoyh esa

uke dks lfEefyr djus ds fy, vkosnu Application for Inclusion of Name in Electoral Roll for First time Voter OR on Shifting from One Constituency to Another

Constituency.

lsok esa]

fuokZpd jftLVªhdj.k vkfQlj]

.................................... lHkk fuokZpu {ks=@ lalnh; fuokZpu {ks=A To, The Electoral Registration Officer, ………………..………………………………………...Assembly / Parliamentary Consitituency

iwjs psgjs dks lkeus ls minf'kZr

djrs gq, uohure QksVks (3.5 CM X 3.5 CM) fpidkus ds

fy, LFkku SPACE FOR PASTING ONE RECENT

PASSPORT SIZE PHOTOGRAPH (3.5 CM X

3.5 CM) SHOWING FRONTAL VIEW OF FULL FACE WITHIN THIS BOX

eS vuqjks/k djrk gwa fd esjs uke dks iwoksZDr lHkh {ks= ds fy, fuokZpd ukekoyh esa lfEefyr fd;k tk;A ¼leqfpr ckWDl ij lgh dk fu'kku yxk;sa½

I request that my name be included in the electoral roll for the above Constituency. (Tick appropriate box)

igyh ckj ds ernkrk ds :i esa ;k vU; lHkk {ks= ls LFkkukUrj.k ds dkj.k

fuokZpd ukekoyh esa lfEefyr fd, tkus ds fy, esjs nkos ds leFkZu esa fof'kf"V;ka uhps nh xbZ gSa&

sa As a first time voter or due to shifting from another constituency

Particulars in support of my claim for inclusion in the electoral roll are given below:- vfuok;Z fof'kf"V;ka Mandatory Particulars ¼d½ uke

vkosnd rFkk lEcU/kh

dk uke fgUnh ,oa

vaxzsth esa vfuok;Z :i

ls fy[kk tk;A vaxzsth

esa dSfiVy ysVj esa

fy[kuk Hkh vfuok;Z gSA

(a) Name (InCapital Letter)

¼[k½ miuke¼;fn dksbZ gks½

(b) Surname(if any)

¼x½ vkosnd ds ukrsnkj dk uke vkSj miuke

¼ns[ksa en ¼?k½ (c) Name and surname of Relative of Applicant [see item (d)]

¼?k½ ukrsnkjh dh fdLe ¼leqfpr ckDl ij lgh dk

fu'kku yxk;sa½

(d) Type of Relation (Tick appropriate box)

firk ekrk ifr iRuh vU; Father Mother Husband Wife Other

¼M-½ vk;q ¼pkyw dSysaMj o"kZ dh 1 tuojh]--------------------

------------dks½

(e) Age [as on 1st January of current calendar year………………..]

o"kZ ekl

Years Months

¼p½tUe dh rkjh[k ¼fnu@ekl@o"kZ ds izk:i

esa½sa¼;fn Kkr gks½½ (f) Date of Birth (in DD/MM/YYYY format)(if known)

/ / /

¼N½ vkosnd dk fyax ¼leqfpr ckDl esa lgh dk

fu'kku yxk,a½

(g) Gender of Applicant (Tick appropriate box)

iq:"k L=h r`rh; fyax

Male Female Third Gender

¼t½ orZeku irk] ftldk vkosnd ekewyh rkSj ij

fuoklh gS

(h)Current address where applicant is ordinarily resident

x`g la0 House

No.

xyh@{ks=@LFkku Street/Area/Locality

'kgj@xzke Town/Village

Mkd ?kj Post Office

fiu dksM

Pin Code

ftyk

District

jkT;@la?k jkT; {ks=

State/UT(i)

¼ i½ vkosnd dk LFkkbZ irk

(i) Permanent address of applicant

x`g la0

House No.

xyh@{ks=@LFkku

Street/Area/Locality

'kgj@xzke Town/ Village

Mkd ?kj

Post Office

fiudksM

Pin Code

ftyk District

jkT;@la?k jkT; {ks= State/UT

¼´½bZihvkbZlh la- ¼;fn tkjh fd;k x;k gS½

(j)EPIC No. (if issued)

oSdfYid fof'kf"V;ka

Optional Particulars

¼V½ fu%'kDrrk ¼;fn dksbZ gks¼leqfpr ckDl ij

(k) Disability (if any) (Tick appropriate box)

n`'; nqcZyrk okd ,oa lquus dh fu%'kDrrk xfr fo"k;d fu%'kDrrk

vU;

Visual impairment Speech & hearing disability Locomotor disability Other

¼B½ bZ&esy ¼oSdfYid½

(l) Email id (optional)

¼M½ eksckbZy la[;k ¼oSdfYid½

(m) Mobile No. (optional)

?kks"k.kk %

eSa ?kks"k.kk djrk gwa fd vius loksZÙke Kku vkSj fo'okl ds vuqlkj %

¼i½ eSa Hkkjr dk ukxfjd gwa vkSj esjs tUe dk xzke@'kgj ----------------------------------------------- ftyk-------------------------- ------------ jkT; -------------------------------- gSA

¼ii½ eSa --------------------------------ls ¼rkjh[k] ekl] o"kZ½ Åij ¼t½ esa fn, x, irs okys LFkku esa ----------------------------------- ----- ls ekewyh rkSj ls fuoklh gw¡(

¼iii½ eSaus fdlh vU; fuokZpu&{ks= ds fy, fuokZPkd ukekoyh esa viuk uke lfEefyr fd, tkus ds fy, vkosnu ugha fd;k gS(

¼iv½ bl ;k fdlh vU; lHkk@lalnh; fuokZpu&{ks= ds fy, fuokZpd ukekoyh esa esjk uke igys ls gh lfEefyr ugha fd;k x;k gSA

;k

esjk uke----------------------------------------------jkT; ds------------------------------------fuokZpu&{ks= ds] ftlesa eSa uhps mfYyf[kr irs ij igys ls gh ekewyh rkSj ls

fuokl dj jgk Fkk fuokZPkd ukekoyh esa lfEefyr dj fy;k x;k gksxk vkSj ;fn ,slk gS rks eSa vuqjks/k djrk gwa fd mls ml fuokZpd

ukekoyh ls gVk fn;k tk,A

DECLARATION:

I hereby declare that to the best of knowledge and belief – (i) I am a citizen of India and place of my birth is Village/Town…………………………..…… .District………………………..…… State……………………… (ii) I am ordinarily resident at the address given at (h) 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/ parliamentary 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.

tks mfpr u gks ml fodYi dks dkV nsaA

* strike off the option not appropriate

ekewyh :i ls fuokl dk iwoZ irk ¼;fn vU; fuokZpu {ks= ls LFkkukarj.k ds dkj.k vkosnu dj jgs gksa½

Address of earlier place of ordinary residence (if applying due to shifting from another constituency) x`g la- House No. xyh@{ks=@LFkku

Street/Area/Locality

'kgj@xzke Town/Village

Mkd?kj Post Office fiu dksM Pin Code

ftyk District jkT;@la?k jkT; {ks= State/UT

eSa bl ckr ls foK gwa fd ,slk dFku ;k ?kks"k.kk djuk] tks feF;k gS] ftlds izfr eSa ;g tkurk gwa ;k fo'okl djrk gwa fd og feF;k gS ;k

mlds lR; gksus dk eq>s fo'okl ugha gS] yksd izfrfuf/kRo vf/kfu;e] 1950 ¼1950 dk 43½ dh /kkjk 31 ds v/khu naMuh; gSA

I am aware that making a statement or declaration which is false and which I know or believe to be false or do not believe to be true, is punishable under Section 31 of the Representation of the People Act, 1950 (43 of 1950).

LFkku Place -------------------------------------------- rkjh[k Date----------------------------------------------- vkosnd ds gLRkk{kj ----------------------------------------------

- Signature of Applicant {ks= Lrjh; lR;kiu vkfQlj dh fVIif.k;ka % Remarks of Field Level Verifying Officer:

dh xbZ dkjZokbZ ds C;kSjs

Details of action taken

¼fuokZpu {ks= ds fuokZPkd jftLVªhdj.k vkfQlj n~okjk Hkjk tk,xk½

(To be filled by Electoral Registration Officer of the constituency)

Jh@Jherh@dqekjh ------------------------------------------------------------------------ ds fuokZPkd ukekoyh esa uke dks lfEefyr djus ds iz:i 6 esa vkosnu dks

Lohdkj@vLohdkj fd;k x;k gSA Lohdkj djus ds [fu;e 18@20@26¼4 ds v/khu ;k vuqlj.k esa½] ;k fu;e 17@20@26¼4½ ds v/khu

vLohdkj] foLr`r dkj.k uhps fn, x, gSa %

The application of Shri / Shrimati/ Kumari …………………………………………………………………………..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)] are given below:

LFkku% Place

rkjh[k % Date bZvkjvks ds gLrk{kj bZvkjvks dh eqgj

Signature of ERO Seal of the ERO

& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &

fy, x, fofu'p; dh lalwpuk ¼fuokZPku {ks= ds fuokZpd jftLVªhdj.k vkfQlj n~okjk Hkjk tkuk gS vkSj vkosnd n~okjk fn, x, irs

ij vkosnd dks Mkd ls Hkstk tkuk gS½

Intimation of decision taken (to be filled by Electoral Registration Officer of the constituency and to be posted to the applicant on the address as given by the applicant) Jh@Jherh@dqekjh --------------------------------------------------------------------------------------------- dk iz:i 6 esa vkosnu

The application in Form 6 of Shri/Shrimati/Kumari…………………………………………………………

fuokZpd

jftLVhdj.k

izkf/kdkjh }kjk izs"k.k

ds le; Mkd fVdV

pLik fd, tkus gSa

Postage Stamp to be affixed by the

Electoral Registration

Authority at the time of dispatch

orZeku irk] ftl ij vkosnd ekewyh :i ls fuokl djrk gS

Current address where applicant is ordinarily resident xg la-

House No.

xyh@{ks=@LFkku Street/Area/Locality

'kgj@xzke Town/Village

Mkd ?kj Post Office fiudksM Pin Code

ftyk District jkT;@la?k jkT; {ks=

State/UT

dks ¼d½ Lohdkj dj fy;k x;k gS vkSj Jh@Jherh@dqekjh ds uke dks----------------------------------------------------------------------------------------------

lHkk fuokZPku {ks= ---------------------------- ds Hkkx la- ------------------------ ds Øe la- ------------------------------------------------ jftLVªhdr dj fy;k x;k gSA

Has been (a) accepted and the name of Shri/Shrimati/Kumari…………………………………………………………………………has been registered at Serial No………………….in Part No…………………….. of AC No…………………………………………………………………….

¼[k½ -------------------------------------------------------------------------------------------------------------------------------------------------------------- ds dkj.k ls vLohdkj dj fn;k x;k gSA

(b) rejected for the reason……………………………………………………………………………………………………………………………………………….

Rkkjh[k% Date: fuokZpd jftLVªhdj.k vkfQlj

Electoral Registration Officer

irk--------------------------------------------------------------

Address….……………………………………………. &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

vfHkLohd`fr@jlhn

Acknowledgement/Receipt

vfHkLohdfr la- &&&&&&&&&&&&&& rkjh[k &&&&&&&&&&&&&&

Acknowledgement Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date __ _ _ _ _ _ _ _ _ _ _ _ _ Jh@Jherh@lqJh &&&&&&&&&&&& &&&&&&&&&&&&&&&&&&&&&& dk iz:i 6 esa vkosnu izkIr gqvk gS

[vkosnd vkosnu dh fLFkfr dh vfHkLohdfr la[;k dks fufnZ"V djrs gq, tkap dj ldrk gS] A

Received the application in form 6 of Shri / Smt. / Ms. ___________________ ______________________________________ [ Applicant can refer the Acknowledgement No. to check the status of application].

bZvkjvks@,bZvkjvks@ch,yvks dk uke@gLrk{kj

Name/Signature of ERO/AERO/BLO

nwjHkk"k ua0

yS0

ykbZu@

Vksy Qzh&

mRrjdk'kh&

01374&222177

01374&1950

peksyh&

01372&252139

01372&1950

:nziz;kx&

01364&233352

01364&1950

fVgjh x<+oky&

01376&232164

01376&1950

nsgjknwu&

0135-2624216

0135&1950

gfj}kj-&

01334-239942

01334-1950

ikSM+h&x<+oky

01368&222217

01368&1950

fiFkkSjkx<+

05964&225236

05964&1950

ckxs'oj

05963&220380

05963&1950

vYeksM+k

05962&230010

05962&1950

pEikor

05965&230296

05965&1950

uSuhrky

05942&235284

05942&1950

m/keflaguxj

05944&246787

05944&1950

vkosnu iz:i&6 Hkjus ds fy, fn'kk&funsZ'k

GUIDELINES FOR FITIXNG UP THE APPLICATION

iz:i&6

FORM-6

1- vkosnu ml fuokZpu&{ks= ds fuokZpd jftLVªhdj.k vf/kdkjh dks lacksf/kr fd;k tuk pkfg, ftlesa os jftLVªs'ku djokuk pkgrs gSaA

fuokZpu&{ks= ds uke dk bl iz;kstukFkZ fn, x, [kkyh LFkku esa mYys[k fd;k tkuk pkfg,A

1.The application should be addressed to the Electoral Registration Officer of the constituency in which he seeks registration. The name

of the constituency should be mentioned in the blank space given for the purpose.

2- igyh ckj ds ernkrk ds :Ik esa ;k nwljs fuokZpu&{ks= ls LFkkukarfjr gksus dh otg ls vkosnu djus okys vkosnu dks mi;qDr ckWDl esa

lgh dk fu'kku yxkuk pkfg, vkSj ?kks"k.kk okys Hkkx esa iw.kZ fooj.k Hkjuk pkfg, vU;Fkk] vkosnu izkjafHkd pj.k esa gh vLohd`r fd;k tk

ldrk gSA

2-The applicant applying as a first time voter or due to shifting from another constituency, should tick the appropriate box, given for the purpose and fill the complete details in the DECLARATION portion,otherwise, the application is liable to be rejected at the initial stage itself.

3- en ¼d½ ls ¼´½ esa fooj.k fn, tkus okys [kkus vfuok;Z gSa vkSj blfy,]mi;qDr en ds izfr iw.kZ lwpuk vfuok;Z :i ls nh tkuh pkfg,A

3. Fields for providing particulars in items (a) to (j) are mandatory and therefore complete information should mandatorily be given

against the appropriate item.

4- en ¼d½ vkSj ¼[k½ % Bhd&Bhd uke vkSj orZuh] tks fuokZpd ukekoyh vkSj fuokZpd QksVks igpku dkMZ ¼,fid½ esa izdV gksuh pkfg,]

miyC/k djk;h tkuh pkfg,A iwjk uke igys ckWDl esa fy[kk tkuk pkfg, vkSj miuke nwljs ckWDl esa fy[kk tkuk pkfg,A ;fn vkosnd dk

dksbZ miuke ugha gS rks miuke ds ckWDl dks [kkyh NksM+ nsuk pkfg,A tkfr dk mYys[k ugh fd;k tkuk pkfg, flok; ,sls ekeys ds ftlesa

tkfr ds uke dk fuokZpd ds uke ;k miuke ds Hkkx ds :i esa mYys[k fd;k x;k gksA info;ksa tSls Jh]Jherh]dqekjh][kku]csxe] iafMr

bR;kfn dk mYys[k ugha fd;k tkuk pkfg,A vkosnd vius uke dk ;fn laHko gks rks] vaxzsth vkSj jkT; dh jktHkk"kk nksuksa esa mYys[k dj

ldrs gSaA

4- Item (a) and (b) : The exact name and spelling as it should appear in the electoral roll and Electors Photo Identity Card (EPIC) should be furnished. The full name should be written in the first box and surname should be written in the second box. In case the applicant does not have a surname, then box for surname should be left blank. Caste should not be mentioned except where the caste name is used as part of the elector's name or a surname. Appellations like Shri, Smt. Kumari, Khan, Begum, Pandit etc. should not be mentioned. The Applicant may mention his name in English and official language of the State both, if possible.

5- en ¼x½ vkSj ¼?k½ ¼ukrsnkj dk uke½% vfookfgr efgyk vkosnd ds ekeys esa firk@ekrk ds uke dk mYys[k fd;k tkuk gSA fookfgr

efgyk vksond ds ekeys esa ifr ds uke vf/kekur% mYys[k fd;k tkuk pkfg,A bl LraHk ls viz;ksT; fodYiksa dks dkV nsaA

5- Item (c) and (d) (Relation's Name): In case of an unmarried female applicant, name of Father / Mother is to be mentioned. In case

of a married female applicant, name of Husband should preferably be mentioned. Strike out the inapplicable options in the column.

6- en ¼M-½ vkSj ¼p½ ¼vk;q ,oa tUefrfFk½% ftl o"kZ ds lanHkZ esa fuokZpd ukekoyh dk iqujh{k.k fd;k tk jgk gS mldh tuojh dh igyh

rkjh[k dks vkosnd dh vk;q 18 o"kZ ;k blls vf/kd gksuh pkfg,A tUe frfFk dks fn, x, LFkku esa fnukad@eghuk@o"kZ ds :i esa vadksa esa

HkjsaA ;fn vkosnd dh vk;q 18 vkSj 21 o"kZ ds chp gS rks tUefrfFk dk ,d nLrkosth izek.k layXu fd;k tkuk pkfg,A tUe frfFk ds

izek.k Lo:Ik fuEufyf[kr esa ls fdlh ,d nLrkost dh izfr layXu dh tk ldrh gS%& uxj ikfydk izkf/kdkfj;ksa ;k tUe&eR;q jftLVªkj

ds ftyk dk;kZy; }kjk fuxZr tUe izek.k&i= ;k cifrLek izek.k&i=] ;k vkosnd }kjk nkf[kyk fy, x, fiNys fo|ky;

¼ljdkjh@ekU;rk&izkIr½ ls ;k dksbZ vU; ekU;rk izkIr 'kS{kf.kd laLFkku ls izkIr tUe izek.k&i= ;k ;fn dksbZ O;fDr d{kk 10 ;k mlls

Åij dh d{kk mrh.kZ gS rks mls d{kk 10 ds vad i= dh ,d izfr nsuh pkfg, c'krZs mlesa tUe frfFk ds izek.kLo:i tUefrfFk nh xbZ gk s]

;k d{kk 8 dk vadi= c'krZs mlesa tUefrfFk nh xbZ gks] ;k d{kk 5 dk vadi= c'krZs mlesa tUefrfFk nh xbZ gks] ;k Hkkjrh; ikliksVZ] ;k

iSu dkMZ] ;k Mªkbfoax ykblsal] ;k ;wvkbZMh,vkbZ }kjk fuxZr vk/kkj i=@dkMZA

6- Item (e) and (f) (Age and Date of Birth): The age of the applicant should be 18 years or more on 1st day of January of the year with

reference to which the electoral roll is being revised. Fill up the Date of Birth in figures in the space provided in DD/MM/YYYY. If the

age of the applicant is between 18 and 21 years, a documentary proof of Date of Birth should be attached. A copy of any one of the following documents can be attached as a proof of Date of Birth:-Birth certificate issued by a Municipal Authorities or district office of the Registrar of Births & Deaths or Baptism certificate ; or Birth certificate from the school (Govt. / Recognized) last attended by the applicant or any other recognized educational institution; or if a person is class 10 or more pass, he should give a copy of the mark sheet of class 10, if it contains date of birth as a proof of date of birth; or Mark sheet of class 8 if it contains date of birth; or Mark sheet of class 5 if it contains date of birth; or Indian Passport; or PAN card; or Driving License; or Aadhar letter/Card issued by UIDAI.

6-1& ;fn mi;qZDr esa ls dksbZ Hkh nLrkost miyC/k ugha gks rks vuqca/k AA ¼fn'kk funsZ'kksa ds lkFk layXu½ esa fn, x, fofgr QkesZV esa ;k rks

vkosnd ds ekrk&firk ds }kjk ¼;k FkMZ tsatj Js.kh esa fuokZpd dh n'kk esa xq: ds }kjk½ ,d ?kks"k.kk nh tk ldrh gSA ftu ekeyksa esa vk;q

ds izek.k Lo:i ekrk&firk dh ?kks"k.kk nh tk ldrh gS] muesa vkosnd dks lR;kiu ds fy, vius vkidks cwFk ysoy vf/kdkjh@lgk;d

fuokZpd jftLVªhdj.k vf/kdkjh@fuokZpd jftLVªhdj.k vf/kdkjh ds le{k is'k djuk gksxkA blds vykok] ;fn mi;qZDr esa ls dksbZ Hkh

nLrkost miyC/k ugha gks vkSj ekrk&firk esa ls dksbZ Hkh thfor ugha gksa rks vkosnd lacaf/kr xzke iapk;r ds ljiap }kjk ;k lacaf/kr uxj

fuxe@uxjikfydk lfefr ds lnL; }kjk fn;k x;k viuh vk;q dk izke.k&i= layXu dj ldrs gSaA

6-1-In case none of the above document is available, a declaration in prescribed format given in Annexure II (enclosed with the

guidelines) made by either of the parents of the applicant (or by guru in case of an elector in third gender category) can be given. In

iz:Ik&6 ds lkFk yxsxk

To be appended to Form-6

those cases where parental declaration is given as proof of age, the applicant will have to be present himself for verification before Booth Level Officer /Assistant Electoral Registration Officer / Electoral Registration Officer. Further, if none of the above documents is available and neither of the parents is alive, the applicant can attach a certificate of his age given by a sarpanch of the concerned Gram Panchayat or by a member of the concerned Municipal Corporation /Municipal Committee.

6-2& ,sls ekeyksa esa ftuesa vkosnd 21 o"kZ ls vf/kd vk;q dk gks vkSj cwFk ysoy vf/kdkjh@lgk;d fuokZpd jftLVªhdj.k

vf/kdkjh@fuokZpd jftLVªhdj.k vf/kdkjh dks mruh vk;q dk izrhr gksrk gks rks mlds }kjk vk;q dh ?kks"k.kk vk;q ds izek.kLo:i yh

tk;sxh vkSj dksbZ Hkh nLrkosth lcwr ij tksj ugha Mkyk tk,xkA vk;q vgZd frfFk ;kfu ml o"kZ dh tuojh dh igyh rkjh[k dh fLFkfr ds

vuqlkj o"kksZa vkSj iwjs gks pqds eghuksa esa bafxr dh tkuh pkfg, ftlds lanHkZ esa fuokZpd ukekoyh dk iqujh{k.k fd;k tk jgk gS@;k fd;k

x;k gSA

6-2- In cases where the applicant is more than 21 years and physically appears to be so to Booth Level Officer/Assistant Electoral

Registration Officer/ Electoral Registration Officer, declaration of age by him / her will be taken as proof of age and no documentary proof will be insisted on. The age should be indicated in years and completed months as on the qualifying date i.e. 1st January, of the year with reference to which electoral roll is being revised /or has been revised.

6-3& ;fn vkosnd u, iathdj.k ds fy, igyh ckj vkosnu dj jgk gS vkSj og o"kZ dh vgZd frfFk dks 21 o"kZ ls vf/kd vk;q dk gS vkSj

mldk uke Hkkjr esa dgha Hkh fuokZpd ukekoyh esa 'kkfey ugha gS rks vuqcU/k AAA ds vuqlkj QkesZV esa ,d ?kks"k.kk nh tkuh gS vU;Fkk]

mldk vkosnu vLohdr fd;k tk ldrk gSA

6-3 If the Applicant is applying for fresh registration for the /first time and he is above 21 years of age on the qualifying date of the year

and his name is not included in the electoral roll anywhere in India, then a declaration has to be given in the format as per annexure III otherwise his application is liable to be rejected.

7& en ¼N½¼fyax½% *iq:"k@efgyk@FkMZ tsaMj ds fy, fn, x, mi;qDr ckWDl esa fyax ij lgh dk fu'kku lqLi"V :i esa yxk;k tkuk

pkfg,A

7- Item (g) (Gender): Gender in the appropriate box provided for 'Male' / 'Female'/'Third Gender' should clearly be tick marked.

8& en ¼t½ ¼orZeku lk/kkj.k fuokl dk LFkku½% vkosnd dks] os orZeku esa tgka lk/kkj.k :i ls fuokl dj jgs gSa vkSj ftls iathd`r

djokuk pkgrs gSa vkSj ftls iathd`r djokuk pkgrs gSa mldk fiu dksM lfgr iw.kZ Mkd irk] dsoy izfof"V fo'ks"k ds fy, fn, x, mi;qDr

LFkku esa Hkjuk pkfg,A

8-Item (h) (Place of Current Ordinary Residence): The Applicant should fill up the full and complete postal address including PIN code where he is ordinarily residing at present and wants to get registered, only in the appropriate space provided for the particular entry.

¼I½ edku ua% ;fn vkosnd ds fuokl esa edku uacj ugha gks rks *edku uacj* ds fufeRr fn, x, LFkku esa bl ckr dk lqLi"V :Ik ls

mYys[k fd;k tkuk pkfg, fd *dksbZ Hkh edku uacj fufnZ"V ugha fd;k x;k gSA**

¼I½ House No.: If the residence of the applicant does not have house number, in the space meant for 'House Number' it should

be clearly mentioned that 'No House Number has been assigned'.

¼II½ lk/kkj.k fuokl ds izek.k Lo:i fuEufyf[kr esa ls fdlh ,d nLrkost dh izfr layXu dh tkuh pkfg,%& cSad@fdlku@Mkd?kj dk

pkyw iklcqd] ;k jk'ku dkMZ] ;k ikliksVZ] ;k Mªkbfoax ykblsal] ;k vk;dj fu/kkZj.k vkns'k] ;k uohure fdjk;k djkj] ;k ml irs ds fy,

;k rks vkosnd ds uke esa ;k mlds fudVre ukrsnkj tSls ekrk&firk vkfn ds uke esa ikuh@VsyhQksu@fctyh@xSl dusD'ku dk

uohure fcy] ;k vkosnd ds uke esa lk/kkj.k fuokl ds irs ij Hkkjrh; Mkd foHkkx ds ek/;e ls Msyhoj dh xbZ dkssbZ Mkd@i=@esyA

¼II½ A copy of any of the following documents should be attached as a proof of ordinary residence: Bank / Kisan / Post Office current

Pass Book; or Ration Card; or Passport; or Driving License; or Income Tax Assessment Order; or Latest rent agreement; or Latest Water / Telephone /Electricity/ Gas Connection Bill for that address, either in the name of the applicant or that of his / her immediate relation like parents etc.; or Any post /letter / mail delivered through Indian Postal Debarment in the applicant's name at the address of ordinary residence

¼III½ cs?kj Hkkjrh; ukxfjd@;kSu dehZ Hkkjrh; ukxfjd%& 'ksM@QqVikFk ij jgus okys cs?kj Hkkjrh; ukxfjd vkSj ;kSu dehZ Hkkjrh;

ukxfjd ftuds ikl lk/kkj.k fuokl dk dksbZ nLrkosth izek.k ugha gS] fuokZpd ukekoyh esa iathdj.k ds fy, ik= gS c'krsZ os fn, x;s irs

ij lk/kkj.k :i ls fuokl dj jgs gksaA

¼III½ Homeless Indian Citizens/Sex Workers Indian Citizens: - Homeless Indian Citizens living in sheds/pavement dwellers and Sex

Workers Indian Citizens, who do not possess any documentary proof of ordinary residence are eligible for enrolment in electoral roll, provided they are ordinarily residing at the given address.

¼IV½ fo|kFkhZ%& gksLVy ;k esl ;k ykWt esa dekscs'k yxkrkj jgus okys] vius lkekU; ?kj ;k fuokl ds LFkku esa dsoy vYi vof/k;ksa ds

fy, tkus okys fo|kFkhZ] ;fn os vU;Fkk ik= gksa] ,sls LFkku ds lk/kkj.k :i esa fuoklh gksus ds :i esa vfHkfu/kkZfjr fd, tk ldrs gSa tgka

gksLVy ;k esl vofLFkr gSA ,sls fo|kfFkZ;ksa dks tks vius vkidks gksLVy@esl esa iathdr djokuk pkgrs gSa iz:Ik 6 ds lkFk

iz/kkuk/;kid@izkpk;Z@funs'kd@jftLVªkj@'kS{kf.kd laLFkkvksa ds Mhu }kjk fof/kor :Ik ls izekf.kr ;FkkFkZ ?kks"k.kk ¼vuqcU/k IV ds :i fn,

x, uewus ds vuqlkj½ layXu djuh gksxhA

¼IV½ Students: Students, if otherwise eligible, living in a hostel or mess or lodge more or less continuously, going back to their normal

home or place of residence only for short periods, can be held to be ordinarily resident in the place where the hostel or mess or lodge is situated. Such students who want to enrol themselves at the hostel / mess will have to attach a bonafide declaration duly certified by the Headmaster / Principal / Director / Registrar / Dean of the educational institution with Form 6 (as per the specimen as Annexure IV).

9- QkssVksxzkWQ% fofunsZ'ku ¼3-5 lseh×3-5 lseh ds lkFk 200 MhihvkbZ fjtkWY;w'ku½ dk gky dk ikliksVZ lkbt dyj QksVks iz:Ik esa bl

iz;kstukFkZ fn, x, LFkku esa fpidk;k tkuk pkfg,A QksVks dk fuokZpd ukekoyh esa vkosnd dh Nfo dks eqfnzr djus vkSj ,fid tkjh djus

ds fy, bLrseky fd;k tk,xkA QksVks esa vkosnd ds flj vkSj da/kksa ds mijh Hkkx dk Dykst&vi n'kkZ;k tk,xkA psgjk fp= ds m/okZ/kj

vk;ke ds 75% dks ysxkA QksVks 'kkiZ Qksdl esa gksuk pkfg,] leqfpr ped ,oa oS"kE; ds lkFk fldqM+u ,oa L;kgh ds fu'kku ls eqDr mPp

xq.koRrk dh gksuh pkfg, vkSj fuokZpd ds psgjs dh izkd`frd Roph; jaxr fn[kuh pkfg, vkSj fof'k"Vrk,a lqLi"V :i ls igpkus tkus ;ksX;

gksuh pkfg,A ;g lgt vfHk;fDr ,oa can eq[k ds lkFk fuokZpd dks lh/ks dSejk ns[krs fn[kk,xhA QksVksxzkWQ fuokZpd dks [kqyh vka[kksa esa

vkSj vka[kksa dks <adus okys fdlh Hkh ds'k@Vksih@Vksi@ixM+h@vkoj.k@Nk;k@ izfrfcac vkfn ds cxSj fn[kk,xkA ;fn fuokZpd p'ek

igurk gS rks QksVkxzkWQ dks vk[ksa p'eksa esa izfrfcafcr dkbZ Hkh jks'kuh ds cxSj lqLi"V :i esa n'kkZuh pkfg,A p'eksa esa jaftr ysal ugha gksus

pkfg, vkSj ;g lqfuf'pr fd;k tk,xk fd p'eksa ds Qzse fuokZpd dh vka[ksa ds fdlh Hkh fgLlsa dks ugha doj djsaA QksVksxzkWQ dh lery]

gYds jax dh i`"BHkwfe gksuh pkfg, vkSj fuokZpd ds lkFk vkSj dksbZ O;fDr ;k oLrq&n';eku ugha gksuh pkfg,A

9- Photograph: A recent passport size Colour Photograph of specification (200 DPI resolution with 3.5c.m x3.5 c.m ) should be pasted

in the space provided for this purpose in the Form. The Photograph will be used to print applicant's image in the electoral roll and issue of EPIC. The photograph shall show a close-up of the applicant's head and the top of the shoulders. The face shall take 75% of the vertical dimension of the picture. The photograph shall be in sharp focus, of high quality with no creases and ink marks with appropriate brightness and contrast and showing natural skin tones of the elector's face and features clearly recognisable. It shall show the elector looking directly at the camera with a neutral expression and the mouth closed. The photograph shall be showing the elector with the eyes open and clearly visible with no hair/cap/hat/headgear/veil/cover/shadow/reflection etc. obscuring the eyes. If the elector wears glasses, the photograph must show the eyes clearly with no lights reflected in the glasses. The glasses should not have tinted lenses and it shall be ensured that the frames of the glasses do not cover any part of the eyes of the elector. The photograph must have a plain, light coloured background and there must be no other people or object visible with the elector.

10- ,fid%

1& tc dHkh Hkh fdlh Hkh Hkkjrh; ukxfjd dk uke fuokZpd ukekofy;ksa esa igyh ckj 'kkfey fd;k tkrk gS] u;k ,fid fcuk fdlh iFkd

vkosnu ds Loeso tkjh dj fn;k tk,xk vkSj mls mfpr ikorh ds v/khu LihM iksLV ds ek/;e ls fu%'kqYd Msyhoj dj fn;k tk,xkA

10- EPIC:

1- Whenever name of any Indian Citizen is included in the electoral rolls for the first time, new EPIC will automatically be issued without

any separate application and delivered to him free of cost, through speed post under proper acknowledgement.

2& LFkku ifjofrZr gksus ij izfrLFkkiu ,fid% ;fn vkosnd us viuk irk ifjofrZr dj fy;k gS vkSj ,sls ifjorZu ij iz:i 6 ;k iz:i 8d

esa vkosnu dj jgk gS rks ,fid ua-] ;fn mls iwoZorhZ fuokZpu&{ks=@irs ij igys gh tkjh fd;k x;k gS] dk mi;qDr LFkku ij mYys[k

fd;k tkuk pkfg,A ;fn og izfrLFkkiu ,fid u, irs ij pkgrk gS rks mls mlds fy, iz:i 6 ;k iz:i 8d ds vk/kkj ij u, LFkku ij

iathdj.k ds ckn izfrLFkku ,fid ds fy, visf{kr 'kqYd] ,oa iqjkus ,fid ds lkFk] iz:Ik ,fid&001 ¼vuqca/k V ds esa :i fn, x, QkesZV

ds vuqlkj½ esa vkosnu djuk pkfg,A

2- Replacement EPIC on shifting: If the Applicant has shifted his address and applying in Form 6 or Form 8A on such shifting, EPIC

No., if already issued to him in the earlier constituency/ address, it should be mentioned at appropriate place. If he wants replacement EPIC with new address, he should apply for the same in Form EPIC-001 ((as per the format as Annexure V), with requisite fee for replacement EPIC, and old EPIC, after enrolment at the new place on the basis of Form 6 or Form 8A.

11- oSdfYid fooj.k

en ¼V½ vkSj ¼M½ esa fooj.k fn, tkus okys [kkus oSdfYid gS] gkykafd] ;g vkosnd ds fgr esa gS fd og bu enksa esa lwpuk miyC/k djk,

rkfd fuokZpu izkf/kdkjhx.k ukxfjd lsok,a tSls vkosnu iz:i] fuokZpdksa dks ,fid Hksts tkus okyh lwpuk@uksfVlksa dks tkjh djus vkSj

fuokZpuksa ds nkSjku ernku dsUnzksa ij vko';d lgk;rk iznku djus] esa l{ke gks ldsaA

11- Optional Particulars

Fields for providing details in item (k) to (m) are optional; however, it is in interest of the applicant to supply information in these

items to enable election authorities to extend citizen services like intimation about status of process of application form, issue of EPIC sending information/notices to electors and providing necessary assistance at polling station during elections.

12&**?kks"k.kk**

¼1½- **?kks"k.kk** Hkkx esa lHkh izfof"V;ka lHkh n`f"V;ksa ls vfuok;Z :i ls iwjh dh tkuh pkfg,A d`i;k og rkjh[k fufnZ"V djsa tc ls vkosnd

orZeku esa fn, x, irs ij fuokl dj jgk gSA ;fn mls rkjh[k ;kn u gks rks ml eghus ,oa o"kZ dk mYys[k fd;k tkuk pkfg, tc ls og

ml LFkku ij fuokl dj jgs gSaA ;fn mldk uke fdlh vU; fuokZpu {ks= dh fuokZpd ukekoyh esa igys ls 'kkfey gS rks ml iwoZorhZ

fuokZpu {ks= ds uke dk mYys[k fd;k tkuk pkfg,A mlds fiNys irs dk iw.kZ fooj.k Hkh miyC/k djk;k tkuk pkfg, vU;Fkk] mldk

vkosnu izkjafHkd pj.k esa gh vLohdr fd;k tk ldrk gSA os fodYi tks lqlaxr ugha gS lkQ&lkFk :i esa dkV fn, tkus pkfg,A d`i;k

uksV djsa fd ?kks"k.kk va'k esa dksbZ Hkh xyr dFku nsuk yksd izfrfuf/kRo vf/kfu;e] 1950 dh /kkjk 31 ds v/khu ,d n.Muh; vijk/k gSA

12-Declaration:- (1) All entries in "DECLARATION" portion must compulsorily be completed in all respects. Please indicate date from which the Applicant is presently residing at the given address. If he is not able to recall the exact date, the month and year from which he is residing at that place should be mentioned. If his name is already included in the electoral roll of any other constituency, name of earlier constituency should be mentioned. Also, full particulars of his previous address should be provided, otherwise his application is liable to be rejected at the initial stage itself. The options which are not relevant should clearly be struck off. Please note that giving any false statement made in the DECLARATION portion is punishable offence under Section 31 of the Representation of People Act, 1950.

¼2½ lsok dkfeZd dks] tks 'kkafr LFky ¼ihl LVs'ku½ esa rSukrh ds vius LFkku ij fuokZpd ukekoyh esa lkekU; fuokZpd ds :i esa iathdj.k dds fy,

vkosnu dj jgk gS] rks mlds iz:i&6 ds lkFk ,d ?kks"k.kk ¼vuqcU/k&I esa½ izLrqr djuh gSA

2- Service personnel, applying for enrolment as general elector in the electoral roll at his place of posting at a peace station, has to submit a

declaration (Annexure-I) along with Form-6.

**********************************************

vuqcU/k&I ¼iz:i&6 ds fy,½

lsok dkfeZd }kjk ?kks"k.kk

¼iz:i&6 ds lkFk layXu fd, tkus ds fy,½

viuh rSukrh ds LFkku dh fuokZpd ukekoyh ds Hkkx esa lk/kkj.k fuokZpd ds :i esa Lo;a dks iathdr

djkus ds fy, eSa]--------------------------------------------------------------------------------- ¼cM+s v{kjksa esa uke½ fjdkMZ dk;kZy;@dekaMsaV }kjk bl

vk'k; dk tkjh fd;k x;k izek.k&i= layXu dj jgk@jgh gWw fd eSa ------------------------------------------------------------¼rkjh[k½ ls 'kkfUr

LFky ¼ihl LVs'ku½] uker%-------------------------------------------------------esa rSukr gqvk@gqbZ gWwA

eSa ,rn~}kjk ?kks"k.kk djrk@djrh gWw fd eSaus fdlh Hkh fuokZpu&{ks= dh fuokZpd ukekoyh ds vafre

Hkkx esa vius vkidks u rks igys ls iathd`r djok;k gqvk gS vkSj u gh fdlh Hkh fuokZpu&{ks= dh fuokZpd&ukekoyh

ds vafre Hkkx esa lsok fuokZpd ds :Ik esa bl izdkj ds iathdj.k ds fy, vkosnu fd;k gSA

eSa ;g Hkh ?kks"k.kk djrk@djrh gWw fd eSa ml fof/k ls voxr gWw tks ,d gh fuokZpu {ks= esa ;k

fHkUu&fHkUu fuokZpu {ks=ksa esa ,d ls vf/kd LFkkuksa ij fuokZpd ds :i esa iathdr djokus dks fuf"k) djrk gS vkSj ;fn

esjk uke fHkUu&fHkUu LFkkuksa ij bl rjg izdV gksrk gS rks mUgsa orZeku LFkku] ftlds fy, iz:i&6 izLrqr fd;k x;k

gS] ds flok; ,sls lHkh LFkkuksa ls foyksfir dj fn;k tk,A

lsok dkfeZd ds gLrk{kj

jSad-----------------------------------------------

LFkku--------------------------------------------

rkjh[k%----------------------------------------

ANNEXURE - I (For Form.6)

DECLARATION BY SERVICE PERSONNEL (TO BE ATTACHED WITH THE FORM-6)

For getting myself registered as general elector in the part of the electoral roll of my place of posting, l,

............... ………………………….............(NAME IN BLOCK LETTERS) am enclosing a certificate issued by Record

Office/Commandant to the effect that I have been posted at the peace station, namely, at .........................................

.............................................................................(place) since………………………..(Date).

l, hereby, declare that I have neither got myself already registered as service elector in the last part of

electoral roll for any constituency nor have applied for such registration as service elector in the last part of the electoral

roll of any constituency.

l, further, declare that I am aware of the law that prohibits getting registered as an elector at more than

one place either in the same constituency or in different constituencies and if my name so appears at different places, the

same may be deleted from all such places except from the present place for which Form 6 has been presented.

SIGNATURE OF THE SERVICE PERSONNEL

RANK……………………………

Place…………………………..

Date........................................

vuqcU/k&II ¼iz:i&6 ds fy,½

'kiFk ;k izfrKku dk iz:i

¼18&21 o"kZ ds vk;q lewg esa igyh ckj ds vkosnd]

ftuds ikl vk;q dk izek.k ugha gS] ds ekrk@firk@xq: }kjk

fy;k tk,@fd;k tk,½

eSa]-------------------------------------------------------------- ftldk uke ---------------------------------------------------------fo/kku lHkk fuokZpu {ks=

dh fuokZpd ukekoyh dh Hkkx la[;k------------------esa dze la[;k--------------------------esa iathd`r gS] bZ'oj ds uke ls 'kiFk

ysrk@ysrh gwWa@lR;fu"Bk ls izfrKku djrk@djrh gwWa fd esjk iq=@esjh iq=h@esjk f'k"; fnukad------------------------------------------

01 tuojh]20----- dh fLFkfr ds vuqlkj --------------------o"kZ dk@dh gS vkSj esjs lkFk jg jgk@jgh gSA

LFkku%&

rkjh[k%&

ekrk@firk@xq: ds gLrk{kj

Jh@Jherh-----------------------------------------------------------}kjk esjs le{k o"kZ 20-----ds -------------------fnol dks --------------------- ¼cts½ -------

----------------------------------------------------¼LFkku½ ij bZ'oj ds uke ls 'kiFk yh xbZ@lR;fu"Bk ls izfrKku fd;k x;kA

fuokZpd jftLVªhdj.k vf/kdkjh@lgk;d fuokZpd jftLVªhdj.k

vf/kdkjh ds eqgj lfgr gLrk{kj

ANNEXURE -ll (For Form-6)

FORM OF OATH OR AFFIRMATION (To be made by either of the parents/Guru of the first time applicant

in the age group of 18-21 years who has no age proof)

l, …………………………………………........... Whose name is enrolled at the Serial No. ............ in the Part No. ........ of electoral roll of the.................................... ..Assembly Constituency do swear in the name of the God / solemnly affirm that my son /daughter/chela ……………… …….……….. is ………………….years of age as on 1st January, 20… and is residing with me. PIace: Date:

Signature of the parents /Guru

sworn in the name of God/solemnly affirmed by Shri/Shrimati……………………… .at…………………………(Place) at…………….. (hour) this the…………………… day of……………………20... before me.

Signature of Electoral Registration Officer / Assistant Electoral Registration Officer with Seal

vuqcU/k&III ¼iz:i&6 ds fy,½

?kks"k.kk* ¼igyh ckj u;k iathdj.k pkgus okys 21$ vk;q&lewg ds fuokZpd ds fy,½

eSa]-------------------------------------------------------------- iq=@iq=h@iRuh ---------------------------------------------------------fuoklh-----------------------------

--------------------------------------------------------------------------------------------------------------fuEufyf[kr ?kks"k.kk djrk@djrh gwWa%&

eSaus-----------------------------------------------------------------------------------------fuokZpu {ks= dh fuokZpd ukekoyh esa iathdj.k ds fy, vkosnu fd;k

gS D;ksafd esjk uke Hkkjr esa dgha Hkh fuokZpd ukekoyh esa 'kkfey ugha gSA

2& eq>s foxr esa fdlh Hkh fuokZpu {ks= esa fdlh Hkh le; dksbZ Hkh fuokZpd QksVks igpku dkMZ ¼,fid½ tkjh ugha

fd;k x;k gSA

LFkku&

fnukad& vkosnd ds gLrk{kj

* ¼fuokZpd ukekoyh dks rS;kj@iqujhf{kr djus ls lacaf/kr ekeyksa esa feF;k ?kks"k.kk djuk yksd izfrfuf/kRo

vf/kfu;e]1951 dh ?kkjk 31 rFkk Hkkjrh; n.M lafgrk ds mica/kksa ds v/khu ,d n.Muh; vijk/k gS½

ANNEXURE.III (For Form-6)

DECLARATION*

(For an elector of 21+ age group seeking fresh registration for the first time)

I……………………….. Son/Daughter/Wife of ………………….................

R/o………………………………………………………………………………………………

……………………….…………..., declare as under: -

I have applied for registration in the electoral roll of .......................................

constituency, as my name does not figure in electoral roll anywhere in India.

2. I have not been issued any EPIC at any time in the past in any constituency.

place: Signature of the Applicant Date: *(Making false declaration in matters related to preparation/ revision of electoral roll is an offence punishable under section 31 of the Representation of the People Act, 1951, and also under the provisions of the Indian Penal Code)

vuqcU/k&IV ¼iz:i&6 ds fy,½

Nk=koklksa@esl@vU;= jg jgs Nk=ksa }kjk ?kks"k.kk

¼iz:i 6 ds lkFk layXu fd;k tk,½

eSa]-------------------------------------------------------------- ¼cM+s v{kjksa esa uke½ iq=@iq=h@Jh@Jherh]---------------------------------------------------¼iSrd

LFkku dk irk½]---------------------------------------------------------------------------------------------------------------------------,rn~}kjk ?kks"k.kk djrk@djrh gWw fd%&

¼d½ eSa---------------------------------------------------------------------------¼laLFkku dk uke½ dk okLrfod Nk= gWw vkSj-------------------------------------------

¼ikB;dze dk uke½ esa ¼o"kZ½ --------------------------------¼ekg½--------------------------------------ls-------------------------------¼o"kZ½ ------------------------¼ekg½ rd -----

---------------------------dh i<+kbZ dj jgk gWwA

¼[k½ eSa orZeku esa&

i½---------------------------------------------------------------------------------------------------- ¼;fn Nk=kokl@esl esa jg jgs gSa rks Nk=kokl@esl

dk dejk la[;k@CykWd la[;k@CykWd uke] vkfn dk mYys[k djsaA

;k

*ii½---------------------------------------------------------------------------------------------------------------------------------------- ¼;fn Nk=kokl@esl ds ckgj

vU;= jg jgs gS rks Nk=kokl@esl ds ckgj fuokl LFkku dk iwjk Mkd irk fy[ksa½ ij jg jgk gWwA

¼x½ *eSa vius ekrk firk@vfHkHkkod ds lkFk vius mi;qZDr fuokl irs ij vius iSrd LFkku dh fuokZpd

ukekoyh esa iathd`r gksuk pkgrk gWw@vius iathdj.k dks cuk, j[kuk pkgrk gWwA

;k

* eSa orZeku fuokl ds fuokZpu&{ks= dh fuokZpd ukekoyh esa iathd`r gksuk pkgrk gWwA

(II½ eSa bl ckr ls voxr gWw fd fuokZpu fof/k ds v/khu ,d ls vf/kd fuokZpu&{ks= dh fuokZpu&{ks= dh ukekoyh

esa ;gk fdlh fuokZpu {ks= esa ,d ls vf/kd ckj iathdj.k djokus dh vuqefr ugha gS vkSj eSa yksd izfrfuf/kRo

vf/kfu;e]1950 dh /kkjk 31 ds nkafMd mica/kksa ls Hkh voxr gWw tks bl izdkj gS%&

**;fn dksbZ O;fDr ¼d½ fdlh fuokZpd ukekoyh dh rS;kjh]iqujh{k.k ;k 'kqf) ds] vFkok ¼[k½ fdlh

izfof"V ds fdlh fuokZpd ukekoyh esa lfEefyr ;k mlesa vioftZr fd, tkus ds laca/k esa] ,slk dFku ;k ,slh ?kks"k.kk

fyf[kr :Ik esa djsxk tks feF;k gS vkSj ftlds feF;k gksus dk ;k rks mls Kku gS ;k fo'okl gS ;k ftlds lR; gksus

dk mls fo'okl ugha gS] rks og ,sls dkjkokl ls] ftldh vof/k ,d o"kZ rd dh gks ldsxh] ;k tqekZus ls ;k nksuksa ls

naMuh; gksxk**

LFkku

fnukad

¼Nk= ds gLrk{kj½

;g izekf.kr fd;k tkrk gS fd mi;qZDr ¼d½ ij ?kks"k.kk esa nh xbZ lwpuk vkSj QksVks dk lR;kiu laLFkku

ds fjdkWMksa ls dj fy;k x;k gS rFkk lgh ik;k x;k gSA

LFkku% iz/kkuk/;kid@izkpk;Z@jftLVªkj@funs'kd@Mhu ds gLrk{kj vkSj eqgj

rkjh[k

bl ckWDl ds Hkhrj iwjs

psgjs dks lkeus ls

minf'kZr djrs gq, gky

dk ikliksVZ vkdkj dk

uohre jaxhu QksVks (3.5 CM X 3.5 CM) fpidkus ds fy, LFkku

ANNEXURE IV(For Form-6)

DECLARATIONBY STUDENTS LIVING IN HOSTELS/MESSES

/ELSEWHERE (TO BE ATTACHED WITH FORM 6)

I, ………………………(NAME IN BLOCK LETTERS), : son/daughter of

………………………………………………………………………..adderss of native place), hereby declare that:-

(a) I am a bonifide student of .........................................................................(

name of the institution) and pursuing ………………...................................................................(details of the course)

from………… .(month)………………..(year) to..............(month) …………......(year)

(b) I am presently residing at - (i) ……………………………………………………………..…………. (if residing in hostel/mess, mention Room

hostel/mess). No./ Block No./ Block Name, etc. of the hostel/mess).

OR

(ii)…………………………………………………………………………………………… (if residing elsewhere outside the hostel/mess, mention complete postal address of the place of stay outside the hostel/mess).

OR

(c) * I want to be registered in the electoral roll/retain my registration in the electoral roll of my native

place at my above-mentioned residential address with my parents/guardian.

OR

*I want to be registered in the electoral roll of the constituency where I am presently residing .

II. I am aware that registration in the electoral roll of more than one constituency or more than once in a constituency is not permitted under the election law and am also aware of the penal provisions of sec. 31 of the R.P. Act,1950, which reads as follows:- " If any person makes in connection with (a) the preparation, revision or correction of an electoral roll, or (b) the inclusion or exclusion of any entry in or from an electoral roll, a statement or declaration in writing which is false and which he either knows or believes to be false or does not believe to be true, he shall be punishable with imprisonment for a term which may extend to one year, or with fine, or with both. Place - Date

(signature of the student)

It is certified that the information given in the declaration at (a) above and the photograph have been verified from the records of the institution and are found to be correct. Place:

Date: Signature and seal of the

Head Master/Princinal/Registrar/Director/Dean

SPACE FOR PASTING ONE RECENT PASSPORT SIZE COLOUR PHOTOGRAPH (3.5 CM X 3.5 CM) SHOWING FRONTAL VIEW OF FULL FACE WITHIN THIS BOX

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-----------------------------------------------------------

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fnukad--------------@-----------@-------------------

fnukad---------@-------@20----

Date: -------_/-------_/20_

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& 20--------

AIINEXURE V (For Form-6) Election Commission of India

ANNEXURE V Application for issue of Replacement Electors Photo lenity Card

(EPIC)

FORM ID

ECI.EPIC-OO1

A State/ UT :

AC (No. & Name):

District:

B Elector's Particulars(To be filled by Elector)

To,

The Electoral Registration Officer, -----------------------------------------------Assembly/ Parliamentary Constituency

Sir/Madam, I request that a Duplicate Electoral Photo identity Card be issued to me as my original card is lost/ destroyed / multilated due to corrections is

my electors detail or due to change of address I want to get a fresh card with my new address. I am retuning my EPIC to you along with fee for issue of duplicate EPIC My name is included in the electoral roll for the above constituency. Particulars in support of my claim for issue of

duplicate EPIC are given below:

1. Name of Elector: 2. EPIC No of Original card ( if known) :.

3. Fathers,/ Mother's/ Husband's* Name :

4. Sex (M/F): 5. Date of Birth (DOB) lf not known then Age in Years) as on

1st Jan,20_......

6. Address (i) House / Door number:

(ii) Street Mohalla / Road/ Gali :

(iii)Area / Locality :

(iv) Town/Village : (v) PIN CODE

(vi) Police Station : (vii) District:

(viii) Reasons for applying for a Duplicate card 1-l will collect EPIC from VRC/CSC 2- I wish to receive my EPIC by Post(self addressed and stamped envelope enclosed) 3- l will collect EPIC from BLO

¼ ½

Signature of the applicant

(ix) Tick ( ) the appropriate box:

I hereby return my mutilated /old card.

I undertake to retum the earlier card issued to me if the same recovered at a later date.

Date

Place

For official Use

Authentication for Issue of EPIC (To be filled by ERO's reperesentative)

Part No. : Serial No. of Elector in Part: lD number of Designated Photography Location (DPL) or Common Service centers

(CSC).:

#Token No. or Receipt No.

Register No. Serial No. in Register

Verified by: Date____/__/20__

Date: -------_/-------_/20_

Signature

D Acknowledgement of R- EPIC by the Elector Received Duplicate EPIC on (Date):---------------------------- Elector's Signature

or Thumb lmpression & 20--------