Gudiya Kumari Voter Form 6
Gudiya Kumari Voter Form 6
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,Bihar Barharia 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 Gudiya गुिडया
(b)Surname(if any) Kumari कुमारी
(c) Name and surname of Relative of
Dinesh Kumar िदनेश कुमार
Applicant [see item (d)]
(d) Type of Relation Father ☐ Mother ☐ Husband ☑ Wife ☐
(e) Age [as on 1st January of current calendar year ]
(f) Date of Birth (in DD/MM/YYYY format)(if known) 01/01/1995
(g) Gender of Applicant (Tick appropriate box) Male ☐ Female ☑ Third Gender ☐
(h)Current address where applicant is ordinarily
House No. 186 186
resident
Street/Area/Locality Pachrukhi पच खी
Town/Village Pachrukhi पच खी
Post Office Pachrukhi पच खी Pin Code 841241
District SIWAN State/UT Bihar
(i) Permanent address of applicant House No
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. (optional) 8294594300
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 Chapra District SARAN State Bihar
(ii) I am ordinarily resident at the address given at (h) above since 01/01/2018 .
(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 / parliamentary constituency
Applicant Place Pachrukhi
Applicant Date 11/10/2020