Ackrowlecaret Number S200890801700241200010 SubrioinDete:- 17-00-2024 ° FORM 8 GY % (See Rules 13(3) and (26) of the Registration of oeM No | Electors Rules, 1960) s ve ELECTION COMMISSION OF INDIA (Tobe fied ofc) Voter Application Form for Shifting of Residence/Correction of Entries in Existing Electoral Roll / Replacement of EPIC / Marking of PwD 73 ‘Thetlectra Regist Ofice, vo aroha ctsen conte we None ake u Orla adNane of Patanentan Cansveny No (@ ‘oy fon Tenors rot hog leila Assen) [| Nae (name ofte spleen. KUKASABA FCN. ayjoyosso8zan8 Asthsr Dts (Peseta [2] aathasrnarber 7pEeR tel lo [os]? |* ® | enol eto furish my Anas Number becaoe| dnt have AadhesrNuber Nabil. of (0) 9 sti [oJe fe sls oti ot ate ten terete eis Ena of e() al dof ah Methane lave ala (W) Isibmitapiestonfor ——_(ekanyoneo te olonng) 1 Siting of Reside (0) 2 [2] coneston a niesn isting eco Rolo) a ssa Replaceret EPC without comet (a) 4 Request formating as Person wt Dist 1. Aplation for hiting of Residence "hare shied ny siden a equestthat myn may be deleted om the previous aes and shite othe cure ass melon low rues thal aenecanert PC ma elssud a re eto changeinmy ads hereby eta myold EP Present oriray [_Housesuldngiapanmert No ‘Sreeareayeaty wohalaood sideceFul | Tonnivlage Pest Ofce tes) PI Code Teh Tagan Die ‘Set Sattateted cop of adres poo eter inte nae of appar anyone ofthe parers/epourfadt chi akeady ele wih at leo atthe ame acest (tach anyone ofthe docurents mend bon") 1 VtseEecioty/Sas io tat adress atleast ya) 2 at cad 3 Curent passbook fNatineaedSchedled Bank PostOfice 4 ian Fsspot 2 peg 5 Revenue Deparrerts Land Owing ecards incutn Kian Bai 6 Retr RertLeae Deed in cs Deed ate of onn huss)_2.Agplleato fr Caraton of Ene in Est Eetral ol nae caret my folovng dts in Hector Rl/EPC: (Warinao entiesparclr canbe coveted) (tack vaso ner) ; = ony ststesesDoammray Pola sport dan tobs state new asoat 1 [2] ee 2] one 3) tie Se wet coL0R = PHOTOGRAPH SCM 4] rewennpe 5 eaten ae 6 seers oq a — 2.5 0M) SHOWING 7D] tebienante ‘ Pho FRONTAL YEW OF FULL FACE WITH WHITE BACKGROUND (ONLY IE PHOTO TORE CHANGED) ‘The coreet pert te ety tobe coca at under Prem Kanwar @= #0) 5351006756 Name of Draenor of above claim attached b a | requst hat aplacemant EPIC mayb sud tome dst changin my personal deals by etn my old EI “Application for Issue of Replacement EPIC wlhowtcoreslon request replacement PIC may bessued ome a ry gral EMC (Putaticn aporopitebor) 1 Lo] ust 2 Destroyed due toreasrbeyend cont ike ods, ether natal str ee a 7) metiated "ery tun my runt old EC (OR Ihave aached coy of FR/olee eportfr lst PIC & undeake treum the eater EPC ood ome ie came acored at altar tage “Applicaton fr Marking Person with isaity Cater of disaityTk te appropri bo for category of sabi) Lecomatve Vel Ore! & Dur [) taxycter eve cesiion) Pacentage of dab. ‘ carte ataced (ek the appropri bow) ve No DECLARATION | HEREBY DECLARE that to the beet of my knowledge and bole that 1am 2 etzen of ina nd | am are that mang a ctatenent or declaration which Ie fle and whieh | know o¢ belve to be fale or do net balleve to ba tus, le pukhale under Sacton 31 of Repetition of the People ACLI960 (42 of 1950) with Impionment for 2 tom whieh may extend to one year or with fe or with bath Date 1705-2028 oc: RAMGARH PRCHARA AoeessuyInerctons: nthe int prodsone of ihe of Ferson wth Debits Act 201 nd ms of Persone win Deablne ue, 2017 case of pereon wh ileal aby, ‘tem cereal ply andmupe abies tsar rl hand tum mpressn of parson wth ably orf grate rltthand hur eration of hs egal urd willbe requ Submission of oe ead coy of menoned GovuneTs wil ene epedy dena of eS eK ‘Acknowledgenent Receipt for apaton eR OR Acker amb $2008908€1703241200010 Date 173-2028 ecied he spplcatonnFurm Bf S/S. UKASABR Kanwar Name/signre of RO/AERO/ELO “This is @ computer generated document and does not teqire signature