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    Form 6

    Uploaded by

    Rafikul Alam
    (1) Anjera Bibi has submitted an application for inclusion in the electoral roll for Assembly Constituency No. 77 Karimpur. (2) She provides her name, father's name (Azahar Mondal), date of birth, gender, address, mobile number, and Aadhaar details. (3) She declares that she is a citizen of India, ordinarily resides at the provided address, and is applying for inclusion in the electoral roll for the first time.

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    Form 6

    Uploaded by

    Rafikul Alam
    59 views3 pages
    (1) Anjera Bibi has submitted an application for inclusion in the electoral roll for Assembly Constituency No. 77 Karimpur. (2) She provides her name, father's name (Azahar Mondal), date of birth, gender, address, mobile number, and Aadhaar details. (3) She declares that she is a citizen of India, ordinarily resides at the provided address, and is applying for inclusion in the electoral roll for the first time.

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    (1) Anjera Bibi has submitted an application for inclusion in the electoral roll for Assembly Constituency No. 77 Karimpur. (2) She provides her name, father's name (Azahar Mondal), date of birth, gender, address, mobile number, and Aadhaar details. (3) She declares that she is a citizen of India, ordinarily resides at the provided address, and is applying for inclusion in the electoral roll for the first time.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    59 views3 pages

    Form 6

    Uploaded by

    Rafikul Alam
    (1) Anjera Bibi has submitted an application for inclusion in the electoral roll for Assembly Constituency No. 77 Karimpur. (2) She provides her name, father's name (Azahar Mondal), date of birth, gender, address, mobile number, and Aadhaar details. (3) She declares that she is a citizen of India, ordinarily resides at the provided address, and is applying for inclusion in the electoral roll for the first time.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Form-6
    [see rule 13(1) and 26] FORM No.
    ELECTION COMMISSION OF INDIA (To be filled by office)
    Application Form for New Voters

    To,
    The Electoral Registration
    Officer, No. & Name of No. 77
    Name Karimpur
    Assembly Constituency
    Or Name
    No. & Name of
    Parliamentary No.
    Constituency@
    (@ only for Union Territories not having Legislative Assembly)
    I submit application for inclusion of my name in the electoral roll for the above constituency.

    (1)(a) Name (In Official Language of State)

    First Name followed by Middle Name


    আনজেরা
    Passport size color
    photograph (4.5cm X
    Surname (if any) বিবি
    3.5cm) showing frontal
    view of full face with
    (1)(b) Name (In English in BLOCK LETTERS) white background

    First Name followed by Middle Name


    ANJERA

    Surname (if any) BIBI

    Disclaimer: If name not filled in English, It will be transliterated by software.

    *(2)(a) Name and Surname (in official language of State) of any one of the relatives:-

    Father Or Mother Or Husband Or Wife

    Or Legal Guardian in case of orphan/Guru in case of Third Gender

    আজাহার মন্ডল

    *(2)(a) Name and Surname (In English in BLOCK LETTERS) of the relative mentioned above

    AZAHAR MONDAL

    (3) Mobile No. of Self (if available) of relative mentioned(Or)


    at Item No. 2
    9641242758

    (4) Email ID of Self (if Available) of relative mentioned at(Or)


    item No.2

    (5) Aadhaar Details:- (Please tick the appropriate box)

    (a) Aadhaar Number 230578770739 (Or)

    (b) I am not able to furnish my Aadhaar Number because i don't have Aadhaar Number.

    (6) Gender

    Male Female Third Gender

    (7)(a) Date of Birth 01-01-1975


    (b) Self attested copy of document supporting age proof attached (anyone of the following)

    (i) Document for Proof of Date of Birth ^:- (Any one of these)

    1. Birth certificate issued by Competent Local Body/Municipal Authority/Registrar of Birth & Deaths

    2. Aadhaar Card

    3. PAN Card

    4. Driving License

    5. Certificates of Class X or Class XII issued by CBSE/ICSE/State Education Boards, if it contains Date of
    Birth

    6. Indian Passport

    (ii) Any other Document for Proof of Date of Birth:- (if none of the above documents is available)(Pl. Specify)

    (8) Present ordinary Residence (Full Address)

    House/Building/Apartment n0152 Tarapur Madhyap


    Street/Area/Locality/Mohalla/Road
    No.

    Tarapur Post Office Gopalpur Ghat


    Town/Village

    Pin code 741122 Tehsil/Taluqa/Mandal Harekrishnapur

    NADIA State/UT West Bengal


    District.

    (b) Self-attested copy of address proof either in the name of application or any one of parents/spouse/adult
    child, if already enrolled as elector at the same address (Attach anyne of them)
    (i) Document for proof of residence ^:- (Any one of these)

    1. Water/Electricity/Gas connection Bill for that address (atleast 1 Year)

    2. Aadhaar Card

    3. Current passbook of Nationalized/Scheduled Bank/Post Office

    4. Indian Passport

    5. Revenue Department's Land Owning records including Kisan Bahi

    6. Registered Rent Lease Deed (In case of tenant)

    7. Registered Sale Deed (In case of own house)

    (ii) Any Other document for Proof of residence:-


    (If none of the above documents is available)(Pl. Specify)#
    (9) Category of disability,if any(Optional)

    Locomotive Visual Deaf & Dumb

    If any other (Give description)

    Percentage of disability: %, Certificate attached (Tick the appropriate box) Yes No

    (10) This details of my family member already included in the electoral roll at current address with whom I
    currently reside are as under:

    Name of family member: Azahar Mondal Relationship with applicant Legal Guardian in case of orpHis/her
    EPIC no.: MMP2649838

    DECLARATION
    I HEREBY DECLARE that to the best of my knowledge and belief-
    (i) I am a citizen of India and place of my birth is:- Village/Town Tarapur District 

    NADIA State/UT West Bengal


    (ii) I am ordinarily a resident at the address mentioned at Sr. No. 8(a) in Form 6 since January, 1975
    (mention month and year)
    (iii) I am applying for inclusion in Electoral Roll for the first time and my name is not included in any Assembly
    Constituency/Parliamentary Constituency.
    (iv) I don't possess any of the documents mentioned at (7)(b)(i)above for proof of Date of Birth/Age. Thererfore, I
    have enclosed (Name of the document) in support of age proof (Strike off, if not
    applicable).
    (v) I am aware that making the above statement or declaration in relation to this application which is false and
    which I know or believe to be false or do not believe to be true, is punishable under Section 31 of Representation of
    the People Act, 1950 (43 of 1950) with imprisonment for a term which may extend to one year or with fine or with
    both.

    Date: 13/11/2022

    Place: Tarapur Anjera Bibi


    Signature of Applicant/Thumb Impression

    Accessibility Instructions:- In the light of provisions of Right of Persons with Disabilities Act 2016 and Rights of Persons with Disabilities
    Rule, 2017, in case of persons with intellectual disability, autism, cerebral palsy and multiple disabilities etc., signature or left hand
    thumb impression of person with disability, or signature or left hand thumb impression of his/her legal guardian will be required.

    Note-
    (*) In case of a married female applicant, name of Husband may preferably be mentioned.
    (^) Submission of self-attached copy of mentioned document will ensure speedy delivery of services.
    (#) In case none of the mentioned documents is available, field verification is must. As for example, category like
    homeless Indian citizens who are otherwise eligible to become electors but do not possess any docmentary proof of
    ordinary residence, Electoral Registration Officer shall designate an offer for field verification.

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