Note : Fields marked with asterisk (*) are mandatory

Form 6

[See rules 13(1) and 26]
Application for inclusion of name in electoral roll
The Electoral Registration Officer
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

Place of Birth Details

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

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

IV Declaration

I hereby declare that to the best of my knowledge and belief: -
(i) I am a citizen of India;
(ii) I am ordinarily resident at the address given in para II above since (year,month,date)

(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;
My name may have been included in the electoral roll

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).