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Chief Electoral Officer, Kerala

FORM 6 [See rules 13(1) and 26] Application for inclusion of name in electoral roll Application No : S11040006002013000022 Hearing Date : 02.03.2013 To The Electoral Registration Officer MALAPPURAM 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: Name: Ummu Salma I. Applicant's details Name in Malayalam : Months: 0 Surname (if any) : Mankarathodi Surname (Malayalam) : Sex (male/female/others): Female Year: 1990

Age as on 1st January : 2013 Date of birth, if known: Place of birth: Day: 01

Years: 23

Month: 01

Village/ Town: Morayur District: Malappuram Name : Mohammed Basheer Name in Malayalam : State: Kerala Surname (if any): Poonthala Surname in Malayalam :

Husband's Name

II. Particulars of place of present ordinary Residence (Full address) House No/ House Name: 1(361) / Basheer Mahal House No/ House Name (Malayalam): 1 / Street/ Area/Locality: Town/ Village/Panchayat/Municipality/Corporation: Morayoor Panchayat Post Office: Morayur Tehsil/Taluk: Ernad District: MALAPPURAM III. Details of member(s) of applicant's family already included in the current electoral roll of the Constituency: Name Mohammed Basheer Relationship with Part number of the roll Serial number Elector's Photo Identity applicant of the Constituency in that Part Card Number Husband 6 4 JCW1637552 Pin Code: 673649

In case of Union territories having no Legislative Assembly and the State of Jammu & Kashmir. # Please give the year i.e. 2007, 2008, etc. * Strike out the inappropriate alternative.

www.ceo.kerala.gov.in/eregistration/eregistrationAppln.html?ApplnId=7c50ef5c-8f55-44ce-972c-53840b0fc133&Auth=de2f859c62daeccbffebeec2b2b2ecc9

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Chief Electoral Officer, Kerala

IV. Declaration I hereby declare that to the best of my knowledge and belief:(i) (ii) (iii) (iv) I am a citizen of India; I am ordinarily resident at the address given in para II above since 7 Month ,0 Year I have not applied for the inclusion of my name in the electoral roll for any other constituency; * 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. Electors Photo Identity Card number (if already issued) : Date of issue _______________________

Full Address (Earlier Place of ordinary residence)

Place :MALAPPURAM Date :03.02.2013 Signature or thumb impression of the applicant

A 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.

www.ceo.kerala.gov.in/eregistration/eregistrationAppln.html?ApplnId=7c50ef5c-8f55-44ce-972c-53840b0fc133&Auth=de2f859c62daeccbffebeec2b2b2ecc9

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