FORM-6 (See Fules 13() and (26 ofthe Registration of ectors Rules, 1960) ELECTION COMMISSION OF INDIA Application Form for New Voters Ackwowiedgement No sts2t00ena70z41200085, (obefiedyofce) ta The Electoral Registration Oficer, No. Name of Assembly Constituency We. (Or No.8 Nameof Partamentary Consttuency@ no, 1 Name, nfo onion Terai eating Loge Assembly) Lt | submit appeaton fer incision of myname the ltr cl forthe above constmuecy Name: Kathud (fe) None il Lenguage ot ie) Fest Name folonedby Middle Name ET Sarai ty) TE (Oy) Name Engh n LOCK LETTERS Fst Name foley Mile Name LAXMAN ‘Suna (Fan) KUMAR Disclamer name not fled n Engh willbe tenltrsted by sofware "(2 a) Name and Sumame(n oficial language of Stat) of any oe ofthe relates: her OF Mosher Husband or wife o v Lega arian in case of omphary Third Gender (@)b) Name and sumame (In Engishn BLOCK LETTERS) of the lative mentioned shove PRNVANKA ie (yea no, of ot ala. f sfefofolo]f«ls][+] (freatve mentioned at temo, 2 | | (Email 0 of Se (fasiabe) or (of reatve menvoned at temo, 2 (uate FEELELCELCECEE (@ender wuz [7 Feats THIRD GENDER (ifa)nate of rth (édimenyy9) 2] elo: 1 eyo |. I Lou L I (b) Se attested copy of documert supporting age prot attached (anyone the following) (@ Docume fr Proof of Date of aren’: (anyon ofthese) 1] _] ith certificate issued by Competent Local Body/Muricipel Authoriy Registrar of iths& Deaths 2) | Aachaer Card al PAN Card 4 Driving License ly) LI i= 5{ | Certificates of class x or class xi issued by CBSE/ICSE/ State EducationBoards, ft contain Date of Birth 6. indian Passport (Any otter Docurent for Proto Date of Birth (fe documertis avaiable (Speci).(@ (8) Present Ordinary Residence Fuladress) Hovs(Bulsing/tperment No, C/O CHAKANKAR BRAMCHANDRA, 1306, ail uesvireaLocety, BANERGAON, aF¥eTA, parva dt ceig. 06, Teh Tauga Mandal HAVEL it ‘TomWilage BALEWADI TTS Post Ofice BANER AFR SiatelUT Maharashtra Distiet Pune Pease 411085 (b) Seitiested copy of ads pool tar inthe name of aplicant ray one of parents/spouse/adul chil fakeady ele as lector at the same adress (tach anyone ofthe) (9 Document fr prot ofresidence*- u Waterlcticy/Gasconnecton al fo thatadéoe(aeat 1 yea) af] sahaar car af] cunt psssbok of Navonaaet/Scedued Bank Post Ot 4 Indian Passport Sf] Revenue Departments Land Owning records clung Kisan Bah 6[] Recstred Rent Lease Deed incase of tenant) 7[ | epletered sale Develicaee of wn house) (any otter nacurant for Proof rsilnces (no dcurant is aval) PSpec) Dest ume (@ycatagory of aby any (Opera) Locomatve Viual anyother (Give description) Parentage of disabity | Potten ek ropa wel] | (10)The dts of my faily mabey inclded nthe electra rol at current adress wih whom cure ese ave a nde Name ffl mente: PRIANKA eaionship wh epic le ihe EP no, ecLaRATION: | HEREBY DECLARE thatthe best of my knowledge ane beiet- (ama citizen of nda ad place of my births TownVilage SALENPUR Diseet: Azamgarh ‘stteUT- uta Pradesh (@) am odnaiyarecdentat the arose mentoned aS. No.8) inForm 6 since: 2010-07 (i) a applying fr ineusen n letra Rel fr the fist time and myname is ot includ in any Assembly Constituency Parometary Constituency. (Ge) dant possess any of he documents of age prot. Therafore, Ihave anclosed: Name ofthe document) support of ge poot Stk off not appliabl). (0) lam aware that making the above statement or declaration in elation to this application whichis false and whch know r believe tbe false or dot believe io be ues purishable under Secon 31 of Representation of the People Act, 1980 (43 of 1950) wth iprconment fr aterm which may extend to one yar or with ine with oth DaTe-07-03-2028 PLACE PUNE ‘Acesitlty instructions Inthe light of provision of Rights of Prcone wth Dcabities Act 206 and Rights of Person wth Diebiltiee le, 2017, nase of pereone with intelectual salty, aus, cerebral palsy and multiple sabes et, signature ort hand thumb impression of person wth sail osgnature ort and th impression of hse legal usr wl be required alee 7 [incase of amaried female applicant name of Hasband may preferably be mertioned = | Sbinisson of elf attested copy of document wil ansre sped dalivery of sins 7 |mease none ofthe documents ie vasbe, fed vefiestin Is musts for example category ke Rameless indian cizen who are otbervise elle became lector but do not Possess any documentary poof of ernar residence, lector Reistion Office shall designate an office fr fil veieation. AclnauladgemeniRaciot ‘Acknowedgemert Number 81321006N0708281200085 are o7- 022008 ecdved he aplation i Form 6 of Sv/SL/M, LAKMAN KUMAR, SESE Lapolsntoan‘etrtheAckonvgernantNo to chick tne sets ct eppcsen This Is 2 computer generated document and does not requre spate =