Eci Citizen Services 1c403q
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11/16/2014
ECI Citizen Services
Applications
Log Out
After you have finalised ,you will not be able to edit your application.You can preview the application by clicking on Preview Button. Do you want to finalize. View/Print Your Form has been submitted successfully. Now you can not modify your form My Applications
http://eci-citizenservices.nic.in/Form6PreviewFinalize.aspx
1/2
11/16/2014
ECI Citizen Services 1 / 1+
फाम / FORM 6
Application ID : ECIS 242162014 F orm 64976
[ नयम 13(1) और 26 दे ख ] / [ See rules 13 ( 1 ) and 26 ]
मतदाता सच दन ूी म नाम लखनेके लए आवे
Application for inclusion of name in electoral roll
से वा म / To , मतदाता पं जीकरण अ धकार - वधान सभा चन ुाव े - Assembly Constituency .
/
photo
/ The Electoral Registration Officer ,
216
महोदय/ Sir , अनरु ोध हैक मे रा नाम उ त नवाचन
े क मतदाता सच ूी म शा मल कर। मतदाता सच ूी म शा मल करने
iम request सहायता that my केname लए be ववरण included नीचे in the दया electoral गया है roll:-for the above constituency . particulars in of my claim for inclusion in the electoral roll are given below :
1 . आवे दक
का ववरण / Applicant ' s
Name : manish
details 1 जनवर को आयु / Age as on 1 st January 201 4 ज म त थ, य द पता है: / Date of Birth , if known
ज म का
थान amauli
/ Place of Birth: relationtype II . 2 .
Surname ( if any ): singh
वष / Years : 20 yr(s)
िजला/ District
उपनाम(य द कोई है ) :
थान का ववरण (परू ा पता) :
particulars of place of present ordinary residence ( full address ) :
मकान / वार संया : House / Door गल / े / ब ती / म ोह ला / रोड :
uttar pradesh
town / village :
kanpur nagar
डाकखाना
:
sujatganj मं डल/ थाना : Tehsil / Taluka / Mandal / Thana :
post office :
तहसील/ तालक ुा/
Surname ( if any ): singh
bank b
street / area / locality / mohalla / road :
क बा / गाँ व :
िजला/ District
पन कोड : pin code :
208013
chakeri
3 . आवे दक केप रवार केउन सद य क ववरण िजनका नाम नवाचन े मतदाता सच ूी III . Details of member ( s ) of applicant ' s family already included in the current electoral roll of the Constituency :
नाम / Name
आवे दक सेर ता / नवाचन Relationship with
1 .
kamlesh singh
F
2 .
malti singh
M
applicant
mobile number :
M
रा य / State : S 24
23
Name : kamlesh
सामा यत: वतमान नवास
लं ग / Sex :
31-01-1994
ाम/ क बा ( Village / Town ): mominpur
नाम :
Father
मह ना / Months : 9 mth(s)
े क सच ूी का
म शा मल ह :
उस भाग म
म
मतदाता क फोटो elector ' s photo पहचान काडidentity सं . /
भाग / Part Number of the roll संया card number / Serial Numbermqj6753941 2264
233
of the Constituency 233
2265 of in that part
mqj6753958
e - mail address : [email protected]
8130316125
.................................................................................................................................................................................... .... वे आ दक Received the application in Form - 6 of Shri / Shrimati / Kumari manish Application ID : ECIS 242162014 Form 64976
Date : 16 - Nov - 2014
क रसीद / Receipt for application
Address ,,
ignature of the officer recceiving the application S on behalf of the Electoral Registration Officer
Copyright © 2011 Election Commission of India. All rights reserved. Designed and Developed by ECI IT Team, New Delhi
http://eci-citizenservices.nic.in/Form6PreviewFinalize.aspx
2/2
ECI Citizen Services
Applications
Log Out
After you have finalised ,you will not be able to edit your application.You can preview the application by clicking on Preview Button. Do you want to finalize. View/Print Your Form has been submitted successfully. Now you can not modify your form My Applications
http://eci-citizenservices.nic.in/Form6PreviewFinalize.aspx
1/2
11/16/2014
ECI Citizen Services 1 / 1+
फाम / FORM 6
Application ID : ECIS 242162014 F orm 64976
[ नयम 13(1) और 26 दे ख ] / [ See rules 13 ( 1 ) and 26 ]
मतदाता सच दन ूी म नाम लखनेके लए आवे
Application for inclusion of name in electoral roll
से वा म / To , मतदाता पं जीकरण अ धकार - वधान सभा चन ुाव े - Assembly Constituency .
/
photo
/ The Electoral Registration Officer ,
216
महोदय/ Sir , अनरु ोध हैक मे रा नाम उ त नवाचन
े क मतदाता सच ूी म शा मल कर। मतदाता सच ूी म शा मल करने
iम request सहायता that my केname लए be ववरण included नीचे in the दया electoral गया है roll:-for the above constituency . particulars in of my claim for inclusion in the electoral roll are given below :
1 . आवे दक
का ववरण / Applicant ' s
Name : manish
details 1 जनवर को आयु / Age as on 1 st January 201 4 ज म त थ, य द पता है: / Date of Birth , if known
ज म का
थान amauli
/ Place of Birth: relationtype II . 2 .
Surname ( if any ): singh
वष / Years : 20 yr(s)
िजला/ District
उपनाम(य द कोई है ) :
थान का ववरण (परू ा पता) :
particulars of place of present ordinary residence ( full address ) :
मकान / वार संया : House / Door गल / े / ब ती / म ोह ला / रोड :
uttar pradesh
town / village :
kanpur nagar
डाकखाना
:
sujatganj मं डल/ थाना : Tehsil / Taluka / Mandal / Thana :
post office :
तहसील/ तालक ुा/
Surname ( if any ): singh
bank b
street / area / locality / mohalla / road :
क बा / गाँ व :
िजला/ District
पन कोड : pin code :
208013
chakeri
3 . आवे दक केप रवार केउन सद य क ववरण िजनका नाम नवाचन े मतदाता सच ूी III . Details of member ( s ) of applicant ' s family already included in the current electoral roll of the Constituency :
नाम / Name
आवे दक सेर ता / नवाचन Relationship with
1 .
kamlesh singh
F
2 .
malti singh
M
applicant
mobile number :
M
रा य / State : S 24
23
Name : kamlesh
सामा यत: वतमान नवास
लं ग / Sex :
31-01-1994
ाम/ क बा ( Village / Town ): mominpur
नाम :
Father
मह ना / Months : 9 mth(s)
े क सच ूी का
म शा मल ह :
उस भाग म
म
मतदाता क फोटो elector ' s photo पहचान काडidentity सं . /
भाग / Part Number of the roll संया card number / Serial Numbermqj6753941 2264
233
of the Constituency 233
2265 of in that part
mqj6753958
e - mail address : [email protected]
8130316125
.................................................................................................................................................................................... .... वे आ दक Received the application in Form - 6 of Shri / Shrimati / Kumari manish Application ID : ECIS 242162014 Form 64976
Date : 16 - Nov - 2014
क रसीद / Receipt for application
Address ,,
ignature of the officer recceiving the application S on behalf of the Electoral Registration Officer
Copyright © 2011 Election Commission of India. All rights reserved. Designed and Developed by ECI IT Team, New Delhi
http://eci-citizenservices.nic.in/Form6PreviewFinalize.aspx
2/2
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