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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 Surname (if any)
I. Applicant’s details
House/Door number:
Street/Area/Locality/Mohalla/Road:
Town/Village:
Tehsil/Taluka/Mandal/Thana:
District:
£
In case of Union Territories having no Legislative Assembly and the State of Jammu and Kashmir.
# Please give the year i.e. 2003, 2004 etc.
* Strike out the inappropriate alternative.
……..……………………………………………..(Perforation)……………………………………………………………………
(Address)………………………………………
………………………………………
2.
IV. Declaration:
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).
House/Door number:
Street/Areal/Locality/Mohalla/Road:
Town/village:
Post Office:
Tehsil/Taluka/Mandal/Thana:
District Pin Code
I am submitting two copies of my recent passport size photograph. One pasted on right side
top corner of Form 6 / Form 8 / Form 8A with my signature/ T.I affixed across the photograph. The
other photograph has been pasted on this application for the purpose of preparation of Elector Photo
Identity Card (EPIC).
I am aware that no EPIC will be issued using this photograph if my claim for inclusion in the
electoral roll in Form 6 or for transposition of entry in Form 8A is not accepted and the photographs
will not be returned to me.
OR
This photograph may be used to replace wrong photograph appearing in the photo electoral
roll against my name as per application for correction made in Form 8.
Place:
Date:
Signature / T.I. of applicant
Note : Please enclose photocopy of some document like Passport, Driving Licence, Arms
Licence etc. showing your photograph and same address as in the application, if available. Show
original for verification at the time of submission of the application and also at the time of field
verification or hearing, if required.
Signature of official