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Application for correction to particulars entered in electoral roll

Your Application No: 
To,

The Electoral Registration Officer,
*Assembly Constituency:  Know Your Assembly Constituency
Sir,

I request that entry relating to myself appearing in the electoral roll the above Constituency is not correct and it should be corrected. Correct particulars in support of my request are given below:
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I. Applicant's Details:
*Name:
Surname (if any):
*పేరు:
ఇంటి పేరు:
Part number of electoral roll:
Serial number in that part:
Date of birth if you know:     Day:    Month:  Year: 
Age as on 1st January 2012: *Years:  Months:  *Gender: 
*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 Elector's Photo Identity Card(if issued, in this or some other constituency)
Elector's Photo Identity Card number:  
Mobile number:  
Name of the Constituency:
E-Mail ID: