Acooneet Naber $400S080212231200009 Submission Dae 25-12-2008 FORM & ] {See Rules 13(3) and (26) ofthe Registration of Electors FORM Wo__ 4 O ules, 1960), wv ELECTION COMMISSION OF INDIA TN Voter Application Form for Shifting of Residence/Cortecton of Entries in Existing Electoral Roll / Replacement of EPIC / Marking of Pw ia ‘Thee Regraten Of, ore ame ot sen Consiveney mm [5 Name Decband No an Name of Premera Casinerey No ane (goiter Un fresno eae Asem) ()Namecteconicart- same sit iene, wroMastO7 ahr Dea Pease tbh pera) [2] astnartanver a | 0) [J ‘amoatet ity tha Nobo becase dt hate ada Nant seat 0 tb bbb he bhp a eer trait SLATE EA enacts allo Fate Metheny er ate i al) (Watt apteatin for kanye felon) 1 ‘siting of eine ‘Z| Corecionot nein xstngBextal Aol) a Iss of Recor EPI whut coestn a) st for mating os Pson wih isity "Applet ter Siting of Restence ‘Iasi scene ad aust nary rameray bedi am te rvs adres an shed te caer less mertoned bo equ aa elcome EPC may eset ome ue change lnm res hey rummy od PC Pree Oy |_ Howse Bulg/Aparme Wo See eaLocaty/ RescecsFul | Toiine Pest tee er) PNGoce Tes Taga da eri Sewit Salant op fetes roar nthe rameof pleat oan ct te apace ci ated enced has elec the cane ates, (atac any oe of te dorunens eines bow) 1 ateEetcyGs i ota acess ales yea) H aes Cat 4 Cure passhst of tone Banos ce 4 Indan Passe ‘ eenveDeprmets an Gunn crs eng is Bat 6 Pegiret Rr Laas Dee inca of ea) Pete Sale Ded case cf nus) Any Ober Sef1. Applet er Creston txts in Exiga Fleas cect my olowing alsin Beto FERC: (sx fener can be are), (Purack ¥ txts apg texto) Cay of eared ecumear Pret spr ofc be sac 1 ae 2 Gane 3) vege J peat ype 5 felon Nave 7 satis | Moblenurber & (2) Pie Trac prulasinth ny tobe caret toad: a Aina a6 (FE aml ane UTTER VELL TTR, >» esmeosse7 art Dh etl oe cm aed 4 |) eC CAC 4) cece casts eet da tn ype Icy yo 1 Apatite sue of Relaenent EPIC wit eanete Ireesttt epaceent PC mae ese te sy orghal PCs (Puateknepooprtebor) 1 los 2 Desay eto reson donc ores foci, one ntl sate 3) mtites hry rum my mise PC (OR avert con of FRPolerepr lot EPIC Iunderaotorene te ale EPCs mel hasan tala sage ‘tne nee Deny aot ay exe sane 6s) J terete Vea [ett [rete eesti Percentage of disaby: (hs Certificate atached (Tick the appropriate box) Cts (J » DECLARATION | HEREBY DECLARE Bat to te est of my Rnowlge and belt tat | am a cen of Ila and | an are tat mang 2 stent or delraton whic i abe an wich | knew ot are t be fase or do nt belle to be tue, i panishable under Secon 3T of Reeser of te People Ac. 1950 (43 of 180) with iprsoonent for & tem wich may eed 10 ne year or with fe or wah bot ate 25.10.2028 ace eed Acces scorn te ght of poss of its of sone iD ct 26nd Rights of Persons Disses les 207 nese pees irc dsbiy cee pay and ute deslies et, sep ot tare tumbnereson cf pason th salty ore patos are har urd eessn ofa gel quran le eure Sibson of se atest pol manned coves wl ersespet evel svi, xo ® ‘Acknowledge Rect fo aplaton IIL RIIIK Acknouedgeent Number: S4MOSORCST223 20008 De2-12-2008 Reese te aplcson nFomof SSO. mee aif Namal Sorare of FO/AEROLO ‘This a coeper gente document and des not require sgt **