E-Registration

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E-REGISTRATION(Form-6)

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Application for inclusion of name in electoral roll

*District : *

To,

The Electoral Registration Officer

*Assembly Constituency: *Know Your 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:

I. Applicant's Details:

*Name:

Surname (if any):

*పేరు:

ఇంటి పేరు:

Date of birth if you know:

Day:

Month:

Year:

Age as on 1st January 2017:

*Years:

Months:

*Gender(Male/Female/ThirdGender):

Place of birth:

*Village/ Town:

*District:

*State:

Father's /Mother's /Husband's Relation Type*

*Name:

Surname (if any):

*పేరు:

ఇంటి పేరు:

II. Particulars of place of present ordinary Residence(Full address)

*House/Door number:

*Street /Area /Locality /Mohalla /Road:

*Town/ Village:

*Post Office:

*Pin Code:

*Tehsil/ Taluka/ Mandal/ Thana:

*District:

III. Details of member(s) of applicant's family already included in the current electoral roll of the Constitutency:

Name:

Relationship with applicant:

Part number of the roll of the Constitutency:

Serial number in the Part:

Elector's Photo Identity Card Number:

Mobile No:

Remarks:

Email-Id: Enter Valid Email ID

IV. Declaration

    I hereby declare that to the best of my knowledge and belif :-

    (1)    I am a citizen of India;
    (2)    I am ordinarily resident at the address gives in para II above since date    month     Year
    (3)    I have not applied for the inclusion of my name in the electroal roll for any other constituency;
    (4)    *My name has not already been included in the electoral roll for this or any other assembly constituency;
                                                                        Or
            *My name 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 my be deleted from that electoral roll.

Full Address (Earlier Place of ordinary residence)

Electors Photo Identity Card number (if
already issued)
Date of issue :
Ex:01/01/1980