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Application for inclusion of name in electoral roll

ApplicationID: 

*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:

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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 2014: *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:
1. 
2. 
Mobile No:  Remarks:  
  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