E-Registration

Chief Electoral Officer
7, Mangles Road, Patna, Bihar

Application For Electoral Roll

Application for the Inclusion of Name in Electoral Rolls

To
The Electoral Registration Officers,
*List(click) Assembly Constituency

Sir,
I Request that my name be included in the electoral roll for the above Constituency. Particulars in support of claim for inclusion in the electoral roll are give below:

Applicants Details	Name: *	Surname(if any):
Age as on 1st January 2004	Years: *	Months:	Sex:* Male Female
Date of Birth(if known)	Day:	Month:	Year:
Place of Birth(if known)	Village/Town:	District:	State:
Relation Details *
Father's Mother's Husband's	Name *	Surname(if any)

Particulars of place of ordinary residence (Full Address)

House/Door Number:
Street/Area/Locality/ Mohalla/Road:	*
Town/Village:	*
Post Office:	* Pincode:
Tehsil/Taluka/ Mandal/ Thana:	*
District:	*
Tel. No.:
Email Address:	*

Details of member(s) of applicant's family already included in the current electoral roll of the Constituency:

Name	Relationship with applicant	Part number of the roll of the Constituency	Serial number in the part	Elector's Photo Identity Card Number

Declaration

I hereby declare that to the best of my knowledge and belief:
(i) I am a citizen of India; (ii) I am ordinarily resident at the address given above since date month year ; (iii) I have not applied for the inclusion of my name in the electoral roll for any other constituency; (iv) * My name has not already been included in the electoral roll for this or any other assembly constituency;
or
* My name may have been included in the electoral roll for constituency in state in which I was ordinarily resident earlier at the address mentioned below and, if so, I request that the same may be deleted from the electoral roll.

Full Address(Earlier place of ordinary residence):

House/Door Number:
Street/Area/Locality/ Mohalla/Road:
Town/Village:
Post Office:	Pincode:
Tehsil/Taluka/ Mandal/ Thana:
District:

Voter's photo identity card(if issued)
Number:
Date of issue:

Place: Date: Signature or thumb impression of the claimant

Note - Any person who makes a statement or declaration which is false and which he either knows or believes to be false or does not believe to be true, is punishable under section 31 of the Representation of People Act, 1950(43 of 1950).