Tlecion Comin inde ‘Application fo a REIT] 9 of Replacement Electr’s Photo Identty Card (EPIC) [sarc —| [ Reo am oa 2 liculare(To be ed by Electo) ] Senesor ‘The Electoral Regisation er, Assamby/ Parlamertay Consttioncy Feturing my EPIC 0 you Naw of Bose request that a Oupteate Electors Photo kentty Cord be asved to me a8. orignal cards lostdesroyedmutiated or de to change of edcress l wantto get aesh ca jong with ee for issue of duplicate EPIC My nar ie mikidadin the woctorl ‘ol forthe above constvency. Patculrs n support of my claim for iesue of cupicate EPIC oe given Criginal ard (i known): Ltn my sew adres, Lam 3 Fathers Mothers? 4 Sex(WFF Husband'* Name: Date of Bh (908) Wot know then Age Yeas)as on eta, 200 hares ()) House Door number (W Seed hahaa Road Gad (Wares Locality ( Towniage | (PIN CODE, (7) Poe Station (wip Distice {ill Reasons for appiying fora Dupicate cad 41. Iwill calec EPI from VRCICSC 2. wish to receive my EPIC by Posso edéressed and stamped enveiope enclosed) 13 wilcollect EPIC fom BLO. a | Th Tick (7 Ve appropriate box: Iereby return my mutated old drd undertake to rtum the eerer card esued to me the same, is rocovered at later date cal Use ‘Authentaton forte of EPIC (Tobe led by ERO's Reprsenave) c ) Sigratue of he applicant Pent [Seria No, of 1D number of Designated Protography “# Toh in No, oF No Elctorin Part: lLecaton (OP. ar Commen Service cantors ocsipt Ne sey: Recisor No [Soi Non Reiser Vertis Received Duplicate EPIC on (Oat): satel 200,