CLAIM APPLICATION FOR INCLUSION OF NAME

[See rules 14(1) and 27) CLAIM APPLICATION FOR INCLUSION OF NAME. To The Electoral Registration Officer. ______________Constituency____________ Municipality, Sir, I request that my name may kindly be included in the electoral roll for the above constituency; in part No________________________ My name (in full)________________________Sex________ My father's/Mother's/Husband's name__________________ Particulars of my place of residence are as under House No___________Street/Mohalla___________________________ Town ___________________District_______________ I, hereby deslare t to the bast of my knowledge and belief that (i) I am a citizen of India (ii) My ags oa the first day of January last was______________ years and_________months. (iii) I am ordinarily resident at the address given above;- (iv) I have not applied for the inclusion of my name in the electoral roll for any oil ter constituency; (v) My name has not been included in the electoral roll for this or any other constituency or my name may have been included in the electoral roll in____________ constituency of____________ Municipality in which I was ordinarily resident of earlier at the address mentioned below and if so, I request that the same may be excluded from that electoral roll. Place______________ Date______________ Signature or thumb impression of claimant. I am an elector in the electoral roll in which the claimant applied for inclusion and my name is enrolled at Serial No in____________________Part No________________of the roll. I support this claim and countersign it. Signature of the elector _________Name (in full)________________________; Intimation of action taken The application in Form 7 of Shri/Shrimati/Kumari________________ address*_______________________ has been (a) (accepted and his/her name has been included in the electoral roll vide Serial No________ in part No, (b) rejected for the reason. ______________________________________________________________________________ Date__________ Electoral Registration Officer (Address)_______________________(Perforation)______________________ Receipt for application Received the application in Form from Shri/Shrimati/Kumari_________________ Address____________________________ Date_______ Electoral Registration Officer Address),,,_____________________ *To be filled in by the applicant Intimation of action taken The objection in Form 7 lodged by Shri/Shrimati/Kumari __________________________Address________________________________ has been: (a) accepted and the name of Shri/Shrimati/Kumari___________________ as appearing at Serial No _____ _in part No.__ ________has been deleted. (b) rejected for the reason__________________ Date_________ Electoral Registration Officer, (Address)____________________ ______________Perforation________________ Receipt for Application Received the application in Form 7 from Shri/ Shrimati/Kumar__________________________________________ Adress _________________________________________________ Date:_________________ Electoral Registering Officer Address_______________________