FORM-6. (See Rules 13(1) and (26) ofthe Registration of Electors Ries, 1960) ELECTION COMMISSION OF INDIA Application Form for New Voters elon edgerent "No So7oBB06No808241 200065, (ote ited by offce} %, “The Electoral Registration Offer, No. &Name of Assembly Constuency Ne. (OF No. &Name of Perierentary Constituency @ No. Name: (Gon for union Tertoves nat having Legislative Aesembs) | submit appicatian forincusion of my name inthe electors rol forthe above constituency. (fa) Nae (offi! Language of State) Fint nave folowesty ote Name. ‘Sumame (if an/) QAR (0) Neve (ergs in 00K LETTERS) Fiot Nave foloweaty ote Name HAPPY ‘Sumame (if any} KUMAR Ovslaime: irae rat le nh wile tantra by otra *(a\(a) Name ard Sumame (in ofeil lenguege of State) of any one ofthe relives = rater || Or Mother (oF Husband on whe or Legal Guattan in ase of phan Third Gender (2ib.) Nave end Sumame (In Engish in BLOCK LETTERS} of the relative mentioned ebove MATHURA SINGH ag (@)Moble No.of set (tf evaléble) 7Pelel2z2)«lsle)s]2l7 Ofrelatve mentioned atte No.2 (4) nal IDof Self (favelebe) hhappyrajpt9540569750 @gmal.com o Ofrelatve mentioned at ter No.2 (6) Aadoar Deas 777 [el[s|+lelel7 i? 3 (6) ender wuz [> FOIE ‘TRO GENDER (7a.,date of ith (darn syyny) [i 2] ¢ ola] @ 2 0 ola (b) Sel attested copy of document suppartng age proof atached (anyone of te folonirg) ()Docurent for Peat of Date of Bith "(Any one ofthese) 1] ) bith cateate issued by Competent Lec Bady/Munipel Authrty Rega of athe & Deshs 2.) hadhase Cod 3) PN ce al | bring License 5 of) indan Passport Coriteates of lass Kor Class Xi sued by COSE/CSE/ Sete EduetonBoart ft contin Date of Birth (i) Ary Other Cocurent for Pref of Dat of Bith: (fro document i avalable) (1. Speci.(@)@) Prosent Ordinary ResKence (Ful Adress) House/Buldng Apartment No. Si Sector-6 FRG RECe-8 ‘Steet/Area/Localty. Seotr-7 SOC8-7 ‘Tehsi/Tatuga tand| Faridabad Wega Town/Vilage Faridabad wetareng Post office fardabad wera State/UT Haryana Distt FARIDABAD Pin Code 121006 (b) Seltatested copy of adress proc ether inthe name of epplicant or any one of parents /spouse/adut chi, aready erred as elector atthe same adress (tach enyone of them) (Document for rot of residence *= 1. | Water/Geotiey (Gos connection Bil for thet edctessatiest 1 yer) 2] Aathaar Cod 3 Ccuret passbook of Nationalied /Schedled Benk/PostOffce 4 Incen Passport 5 Revenue Departments, Land Owing records heladng Kisan Beh 61 | Registered Ren Lease Deed(ncase of tenant) 7 Reg)stered Sule Deed(ncese of ann house) (iy ary omer Cooument for Fret of resicence fro docurent s evalibie} (1 Speci) (@ioutegory of ably, fey (Optens) Lecoretive Vieul Dest, uenb Itany other (Give desertion) Percentage of dsabily js oetfate atached (Tick the appropriate tox) Yes. Ne (oyThe cet of wy feriy ember already ince inthe electoral rol et curent adress with whom leurenty reside ae es under Name of fay martber Relatonship with appleant: Hisiher er1¢ ne DECLARATION - HEREBY DECLARE that to the best of my knowledge and beet - (1am acitzen of nda and place of my bith = TownvVilage Faridabad Disc: FARIDABAD ‘State UT: Haryona (G1 crv a resident atthe adress mentioned at St. No. O(n Fo 6 since: 2004-01, (GU) am applying for nclsion in ectoral Rel forthe st ime and my name i not ced in ny Assembly Constiuency Parlamentary Constituency (i) ort possess any of the documents of age pron. Therefore | have enclosed: (ame of the document) in suppart of age proof (Strike off, not applicable). (Lam aware tat making the above statement or dectaratlon in felaon to Ws applkatlon which false and which | know or Leeve tobe false of donot bekeve to be ‘te, pnisheble under Section 3 of Representation of the People Act, 1950 (49 of 1960) with impriscoment fora term which may extend to one year or WA fine or wit tot, DATE 09-04-2024 PLACE -FARIDABAD ‘Accessily Instructions Inthe Bg of provisions of Fights of Persons wih Disabites Act 2076 and Rights of Persons wih Dkables Rules, 2017, case of persons wit ntlloctal disabity, autism, cerebral pal and mule dsabiltes etc, signature or left hand thumb impression of person with sabily or signature o left hand ‘thumb impression of tis er egal guaran wl be requed. Note: * |Incase ofa marred female applicant name of Husband may preferably be mentioned * | Submision of se-atested copy of document wil ensure spesty debvery of services + incase none of the documents is avalble, field verication i must. As fr example, category ike homeless Indlan citizens who are otherwise elgible to become electors but do aot possess any documentary prot of ordinary residence, Electoral Reisaion Officer shal designate an officer for field verfcatin ‘Ackomwvedgement eceist Ackowedgerrent Nurber $0708906N 0804241200065 DATE 9-08-2024 Receve the applestion n Form 6 of Stn /Sme./¥s. Happy Kumar UR rR Lepplcant canreter the Ackoonedgement No. to check the status of appcation] ft THis Is a computer generated document and does not rogure signature **