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Voter Registration Form-6 Submission

Samiran Ghosh has applied for inclusion of his name in the electoral roll for the first time. He is 18 years old and resides at House No. n0109, Debagram Chatterjee Para in Debagram village, Nadia district of West Bengal. His father's name is Nimai Ghosh. He declares that he is a citizen of India born in Debagram village, and has lived there since 2002. He also declares that he has not applied to be included in any other constituency's electoral roll and his name is not already included in any roll.

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PARTHA GHOSH
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311 views2 pages

Voter Registration Form-6 Submission

Samiran Ghosh has applied for inclusion of his name in the electoral roll for the first time. He is 18 years old and resides at House No. n0109, Debagram Chatterjee Para in Debagram village, Nadia district of West Bengal. His father's name is Nimai Ghosh. He declares that he is a citizen of India born in Debagram village, and has lived there since 2002. He also declares that he has not applied to be included in any other constituency's electoral roll and his name is not already included in any roll.

Uploaded by

PARTHA GHOSH
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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12/20/2020 @ViewBag.

Title

ELECTION COMMISSION OF INDIA


FORM-6
(See Rules 13(1) and 26) of Registration of Electors Rule-1960

Application for Inclusion of Name in Electoral Roll for First time Voter OR on
Shifting from One Constituency to Another Constituency.
To, The Electoral Registration Officer,West Bengal Kaliganj Assembly / Parliamentary Consitituency
I request that my name be included in the electoral roll for the above Constituency.
(✓) first time voter
Particulars in support of my claim for inclusion in the electoral roll are given below:-
Mandatory Particulars
(a)Name SAMIRAN সিমরন
(b)Surname(if any) GHOSH ঘাষ
(c) Name and surname of Relative of
NIMAI GHOSH িনমাই ঘাষ
Applicant [see item (d)]
(d) Type of Relation Father ☑ Mother ☐ Husband ☐ Wife ☐
(e) Age [as on 1st January of current calendar year
2021]
(f) Date of Birth (in DD/MM/YYYY format)(if known) 03/12/2002
(g) Gender of Applicant (Tick appropriate box) Male ☑ Female ☐ Third Gender ☐
(h)Current address where applicant is
House No. n0109 এন0109
ordinarily resident
Street/Area/Locality DEBAGRAM CHATTERJEE PARA দব াম চ াটাজ পারা
Town/Village DEBAGRAM দব াম
Post Office DEBAGRAM দব াম Pin Code 741137
District NADIA State/UT West Bengal
(i) Permanent address of
House No
applicant
Street/Area/Locality
Town/Village
Post Office Pin Code
District State/UT
(j)EPIC No. (if issued)
Optional Particulars
(k) Disability (if any) Visually Impared ☐ Speech hearing disabled ☐ Locomotor disability ☐ Other _________
(l) Email id (optional)
(m) Mobile No.
9883714432
(optional)
DECLARATION - I hereby declare that to the best of knowledge and belief –
(i) I am a citizen of India and place of my birth is Village/Town DEBAGRAM District NADIA State West Bengal
(ii) I am ordinarily resident at the address given at (h) above since 03/12/2002 .
(iii)I have not applied for the inclusion of my name in the electoral roll for any other constituency.

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12/20/2020 @ViewBag.Title

*(iv)My name has not already been included in the electoral roll for this or any other assembly / parliamentary constituency
Applicant Place DEBAGRAM
Applicant Date 20/12/2020

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