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S r.l reqlest that nry name be ncluded n thc e ectora ro I fcr thc above Consliluen.y Pariiculars if slppod of my cla m ior .rcllsion n the eclor.l rol are given below :
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:rciE] qld-f,I t Receipt for application
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Signai!re ofthe officer receiv n9 the appllc6Ucn on beharfolthe Elecioral Regisirciion Officer
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i ) l am a c trzcn oi Lnoia: O L . f r i,,dlfa r ily .csld eni at l . addrcss givcn in (caic, monlh yea,)tliir) lhave Noi appliecl loi lhc inclusionot roll for any othcr mnstitucnLy ( v) Ll y ndmc hr. noi ,r, ., d? bF.. , ' Lcled rn the elecior.l roJl for tL is or any other Assembiy Consiiilencyj Or 'My name may havc bccn includcd in lhe elccio I r{Jl lor l Slate in \dhnjh I $,as ordinarily , cs dc nt ca r , !r li c addrcss mentioncn below and if so, I C o. slitrcn.:! in A rcquest that lhe same may be dc{eted from that clcctoral roll. 'iin (ciq Fan-{x, dRdd k. r) / Full address (Earlic. placc oi Ordinarily Resiclcfce) A
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Signature oi Elcctoral Regisiraiion Olf.cr
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Proof oi Oridinary Residence lo be attached (a/ryore) 1. Lighl Blll2. rlephone Bil! 3. [4Obi]e B ll4. Rent Recelpt 5. Bank / PcstPasstr00k 6. PrOpedy Agreemenl 7. Leav"" and Licence Agreement 8. Passp0rt L Ratiorca'd 10 Ceiifcate ftom Super;nlendant in case 0f percons living
n Hosle i 0 d Age Honre etc Age Proo{ | Sch00 Leav ng Certilicale {T.C.) / Blrlh Ceri flcate I ltlaff age Cerlilicale elc
