PART NO :0

13(1) 26

Application ID :
111695369

/ FORM 6

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

/
Application for inclusion of name in electoral roll

/ To,

/ The Electoral Registration Officer,

(GEN)

5 -

5 - BADLI (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 2016 /
Age as on 1st January 2016
,

( ) :

Name : ASHOK

Surname (if any) :

/ Place of Birth

Father's Name :

II.
2.

: ( )

/ Months :

/ Sex :

Male

(Village/Town) : ABDULPUR

District : UTTARDINAJPUR

/ State : WEST BENGAL

( ) :

Name : DIREN VALA

Surname (if any) :

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

GALI NO-8

: House / Door No.:

/ / / / :
/

SAMAIPUR

Town / Village :

SAMAIPUR

Post Office :

S-84

SWAROOP NAGAR

Street / Area / Locality / Mohalla / Road :

02-Jan-1978

: / Date of Birth, if known

37

/ Years :

110042

Pin Code :

SWAROOP NAGAR

: 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:

1.

/ Name

BHAGWAN SINGH

/
Relationship with
applicant

/ Part Number of the roll

of the Constituency

Brother

2.
Mobile Number : 9540422040

/ Serial Number
of in that part

./
Elector's Photo Identity
Card Number

KSP1490481

E-Mail Address : ZAHID6160@GMAIL.COM

....................................................................................................................................................................................
....
Application ID : 111695369

/ Receipt for application

Received the application in Form-6 of Shri/Shrimati/Kumari ASHOK Address S-84, SWAROOP NAGAR, DELHI

Date : 18-Jan-2016

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)

(, , )

05-Feb-2003

(iv) *
(i)
I am a citizen of India.
(ii)
I am ordinarily resident at the address given in para II above since
(date, month, year)
05-Feb-2003
(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) :

Not Applicable

/ Electors photo Identity Card (if already

Number :
:
Date :

:
Place :

Not Applicable

. (

18-Jan-2016

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. ASHOK 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.)