Acknowiedgent Number: Submission Date:-0340-2028, siaes08cotosto10 FORM 8 (See Rules 13(3) and (26) of the Registration FORMNO____ of Electors Rules, 1960) Ye ELECTION COMMISSION OF INDIA (ets Voter Application Form for Shifting of Residence/Correction of Entries in Existing Electoral Roll / Replacement of EPIC / Marking of PwD Te, ‘The Electoral Registration Oficet, No, nd Name of Assembly Consttuency No. [a5 | Name Bhokar (OrNo. and Name of PatlamantaryConsttuency No, Name (een fren farang got seer) ()Nameof he eppicent- Chandpasha Nasabegam EPICN.—_xHKS071204 AadheatDetas- (Please tikthe anoroprite bon) (@) [2] Aadtaar Number (s [4 Js [e]o[s Je [o[2lol7[e]o (©) [J Lamotte to funsh my Aachar Numba: ezaseldonthae haha Number (ef eTef [Jets [2 fa] Mobloni.of aon Noble. ofFathrMthexny tert iar) Clr CCC smal it Se (on mal dof Father Mother/Any ther relative f avalble) (W) leubmitppcatonfor (lek anyone he folonng) 1. [] Sitting of Residence (09 2 [Fo) conecton ct itesn tng Er Ro a. [-_] ‘ese o Replacement Ee wthut erection) 4 | Request for maikng as Parson with Disability 1. Applicaton for Shifting of Residence Ihave sited my residence and Irequest that my name may be deleted from the previous adress and shed tothecuren adess mentioned below | eques that replacement EPIC may be issue tome due to change in my adress hereby retun my old EPI. Prcrt Oran] Houte/budnpavarmen io] Stew Weald rescence "| Tomiiage Pos ice races) | BNoode Tek aaa Dist suai ‘Setattested copy of acres poo ether inthe name of applicator enyone o he parents/spouse/adut chili already enrolled wih as electra the same adress (attach any one ofthe documents mentioned below 8 1.) Watery Gos itor des atest ye) 2) patterns 3] canentpssootornatonaeasenetieszancrostonce 4 [Indian asso eve Deparmens and Oming recor ieng sande 6, [] Retr artes Ded aoa 7. [J Rasta ee beeen case of ono ‘Any Other: (PL Spec),2. Applicaton fo Correction of Ene in Existing Electoral Rol Pease corect my folowing details Electoral ROWEPIC (Maximum oF 4 eines/pariulars canbe corected) (Puta tek v snescnaporopate bx elon) Copy of sett atested Documentary Prootn supporto clam tote attache. 1. [oe] Nome 2] cede 2 [1 vobie 6 relator ype 5. [2] Relaton name 6] aatess 1. a) Meenas Do] Peto r ‘The correct particulars inthe entry tobe conectad are asunder © | nasica segum Stalin chandpashe (afar dam te igs) >| shan Chanapasna (tar igen ) CT eanert9628 Name of Documentin support of above csi attached 8 padhaae Card bT padtaae Card 4 request that a replacement EPIC may be issued to me due to change ny personal deta [hereby return my ok EPIC. ‘3 Application for Issue of Replacement EPIC without correction I request thats eplacenent EPIC may be issued to me asm original PICs (Puta ickin appropriate bor) 1 [] wt [ested ato eson beyond contol be foods ote naval ater te 3 nites | hereby retum my must! old EPIC (OR) have attached copy of FIR/Polie report fo ost EPIC BI undertake to retumn the eatler EPC Issued to melt the samels recovered ats later tage. “Applicaton for Marking Person with Disability Category of csabilty (Tek the appropiate box for category of saiy) Losmatve — [] aul [J] ests rane 1 tanya esrten Pescentageof sity x Cartfeate tached Tikthe aroroorteb0n) es Wo DECLARATION | HEREBY DECLARE that to the best of my knowledge and belle that | ams ctizen of India and 1 am aware that making & statement or declaration Which Is flse and which I know or bellove to be false or do not believe to be true, Is punishable under Section 31 of Representation of the People ‘ct1950 (43 of 1950) with imprisonment for a torm which may eatend to one year oF with fine ot with both Date:03-10-2023 Proce: bhokar ”Acoessibity structions nthe ight of powsons of Rghs of Persons with Disables Act 2076 and Rights of Persons wth Disables Rules, 2017, cae of persons with intelectual sab, autism, eebral palsy and multiple disables etc, signature or lt hand thumb impression of patson with sbi, ora signature or let hand hum impression of s/he egal quarlan lb equted * Subiission of siattesied copy of merioned documents wil ensure speedy daivery of sevices = RR “Acknowledgement Recep or application =» RR ‘Acknowledgement Number -$190850860810231200010 Date: 03-10-2023 Racelved he application n Form @ of SheSmt/MB. Chandpasha Nasiabegam Namalsig of ERO/AERO/BLO This Is a computer generated document and does not require signature **