[

13(1) 26

Application ID :
6944373

/ FORM 6

] / [See rules 13(1) and 26]

/
Application for inclusion of name in electoral roll

/ To,

69 -

/ The Electoral Registration Officer,

(GEN)

69 - MUSTAFABAD (GEN) 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 :

1.
details

/ Applicant's

1 2015 /
Age as on 1st January 2015
,

( ) :

Name : RAKESH KUMAR VERMA

Surname (if any) :

/ Place of Birth

Father's Name :

II.
2.

: ( )

/ Months :

/ Sex :

Male

(Village/Town) : DELHI

District : DELHI

/ State : DELHI

( ) :

Name : SHYAM LAL VERMA

Surname (if any) :

Particulars of place of present ordinary residence (Full address) :

A-7

: House / Door No.:

/ / / / :

Street / Area / Locality / Mohalla / Road :

/

GOKALPURI

Post Office :

GALI NO 3
AMAR VIHAR

Town / Village :

01-Jan-1977

: / Date of Birth, if known

38

/ Years :

110094

Pin Code :

GOKALPURI

: Tehsil /Taluka/Mandal/Thana :
DELHI

District

3. :
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
of in that part

1.

2.

Mobile Number : 9716741020

./
Elector's Photo Identity
Card Number

E-Mail Address : ANWARMOHD820@GMAIL.COM

....................................................................................................................................................................................
....
Application ID : 6944373

/ Receipt for application

Received the application in Form-6 of Shri/Shrimati/Kumari RAKESH KUMAR VERMA Address A-7, GALI NO 3, DELHI

Date : 16-Nov-2014

Signature of the officer recceiving the application

on behalf of the Electoral Registration Officer

IV. / Declaration

: / I hereby declare that to the best of my knowledge

and belief :(i)

(ii)

(iii)

01-Jan-2010(, , )

(iv) *
(i)
I am a citizen of India.
(ii)
I am ordinarily resident at the address given in para II above since 01-Jan-2010
(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 requested that the same may be deleted from that electoral roll.
--------------------------------------------------------------------------------------------------------------------------------------------------------------

(:

Full Address (Earlier place of ordinary residence) :

. (

/ Electors photo Identity Card (if already

Number :
:
Date :

:
Place :

16-Nov-2014

Date of Issue :

Signature or thumb impression of the applicant

, 1950(1950

43)

31

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)
/ Details of action taken
( )
(To be filled by Electoral Registration Officer of the constituency)

6 * /

The application of Shri/Smt./Km. RAKESH KUMAR VERMA for inclusion of name in the electoral roll in Form 6 has been
accepted*/recjected*.
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)]:
Place:
Date:

Signature of Electoral Registration Office

(Seal of the Electoral Registration Officer)

( , , ) / Remarks of
Field Level Officer (e.g. BLO, Designated Officer, Supervisory Officer.)