uequk 8v/FORM 8A

[Ikgk

fu;e 134 vkf.k 26/ [See rules 13(4) and 26]

ernkj ;knhrhy uksanhps LFkkukarj dj.;klkBh djko;kpk vtZ

Application for transposition of entry in electoral roll
izfr@ To,
ernkj uksan.kh vf/kdkjh@The Electoral Registration Officer,
.. fo/kkulHkk ernkjla?k@ Assembly Constituency.
Ekgksn;@Sir,
Ekh mijksDr ernkj la?kkP;k ernkj ;knhrhy ek;k Lor%P;k @[kkyh uewn dsysY;k O;DrhP;k ukokph uksan ;k ernkj
la?kkrhy lacf/kr Hkkxke/;s LFkkukarfjr dj.;kr ;koh] vkh fouarh djhr vkgs- LFkkukrj.k djko;kP;k uksanhckcrpk rikhy
[kkyh ns.;kr ;sr vkgs%&
I request that the entry in the electoral roll for the above mentioned constituency relating to "'Myself / *person
named below should be transposed to the relevant part of the roll in this constituency. Particulars of the entry to be
transposed are given below:
I. T;k O;fDrP;k uksanhps
vkMukao vlY;kl@Surname(if any)
Name

LFkkukarj.k djko;kps
vkgs frpk rikhy

Details of person
whose entry is to be

transposed:
OkfMy@ Fathers
vkbZ@ Mothers
Ikrhps@husbunds
II.
LkkekU;r% fuoklkP;k

ukao@

Ekrnkj ;knhP;k T;k Hkkxke/;s R;kps@ frps Hkkxkrhy R;kpk@frpk

uko lekfoV vkgs R;k Hkkxkpk ekad@
vuqekad His/her
Part number of electoral roll in which his/her
name is included:

uko

serial number in that

part:

Ekrnkj vksG[kIk= ekad

fnys vlY;kl Elector's
Photo Identity Card (if
issued) Number:

vkMukao vlY;kl@Surname (if any)

uko@/Name

Name

fBdk.kkpk rikhyiw.kZ IkRrk@Particulars of place of ordinary residence(Full address):

?kj ekad@House/Door number:

jLrk@{ks=@olfrLFkku@eksgYyk@ekxZ@Street/Area/Locality/Mohalla/Road:
xkao@kgj@Village/Town:
Mkd dk;kZy;@Post Office:
fiudksM@Pin Code:
rgfly@rkyqdk@eaMG@Bk.ks@Tehsil/Taluka/Mandal/Thana:
ftYgk@District:
III. vtkZP;k fnukadkyk vtZn kjkP;k mijksD r IkRR;kojhy lrrP;k
Okks%Z
Years:
okLrO;kpk dkyko/kh Period of continuous residence at the

efgus%
Months:

above address on the date of application

IV. T;k Hkkxke/;s uksan LFkkukarfjr djko;kph vkgs rks Hkkx ekad Kkr vlY;kl
Part number to which the entry has to be transposed (if known):
V.
uko@Name
vkMuko

vtZnkjkpk
rikhy

Details of
Applicant:

Ekrnkj ;knhP;k T;k Hkkxke/;s R;kps@frps

uko lekfoV vkgs R;k Hkkxkpk ekad@
Part number of electoral roll in which
his/her name is included:

vlY;kl@Surname (if any)

Hkkxkrhy R;kpk@frpk vuqekad

His/her serial number in that
part:

Ekrnkj vksG[kIk= ekad fnys

vlY;kl Elector's Photo
Identity Card (if issued)
Number:

* udks vlysyk Ik;kZ; [kksMkok@Strike out the inappropriate alternative.

@
tj vtZnkjkl Lor%ph uksan LFkkukarfjr djko;kph vlsy rj Hkkx 5 Hkj.;kph vko;drk ukgh@ Part V not to be filled where applicant
seeks transposition of entry relating to himself.

-ek-Ik-@ P.T.O.
.Perforation....

vtkZph ikorh@ Receipt for application

Jh@Jherh@dqekjh--------------------------------------------------------------------------;kapk uequk 8v e/khy vtZ izkIr >kkykReceived the application in Form 8A of **Shri/Shrimati/Kumari..
**IkRRkk@Address..

fnukad@Date.

Ekrnkj uksan.kh vf/kdk;kP;korhus vtZ fLodkj.kk;k vf/kdk;kaph Lok{kjh

Signature of the officer receiving the application on
behalf of the Electoral Registration Officer

IkRrk@(Address)
** vtZnkjkus Hkjko;kps@To be filled in by the applicant.

IkzfrKkiu]
Ekh ;kOnkjs vls ?kksfkr djrks dh] oj uewn dj.;kr vkysyh oLrqfLFkrh vkf.k rikhy ek;k laiw.kZ ekfgrh o
fooklkizek.ks lR; vkgsIV. Declaration

I hereby declare that the facts and particulars mentioned above are true to the best of my knowledge and belief.

fBdk.k@Place:

fnukad@ Date:

vtZnkjkph Lok{kjh fdaok vaxB;kpk Blk

Signature or thumb impression of claimant

Vhi%& dks.krhgh O;Drh ts [kksVs vkgs vls fryk ekghr vkgs fdaok ts [kksVs vkgs vls fryk okVrs fdaok ts [kjs vkgs vls fryk okVr ukgh vls
fuosnu fdaok izfrKkiu djhy rh O;Drh yksdizfrfu/khRo vf/kfu;e] 1950 P;k dye 31 vUo;s fk{ksl ik= BjsyNote - 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 the People Act, 1950 (43 of 1950).
* udks vlysyk Ik;kZ; [kksMkok@ Strike out the inappropriate alternative.

dsysY;k dk;Zokghpk rikhy@ Details of action taken

ernkj la?kkP;k ernkj uksan.kh vf/kdk;kus Hkjko;kpk@(To be filled by Electoral Registration Officer of the constituency)
Jh@Jherh@dqekjh--------------------------------------------------------------------------;kapk ernkj ;knhe/;s ukao lekfoV dj.;klkBh
uequk 8v e/khy vtZ fLodkjyk@ukdkjyk
The application of Shri/Smt./Km. ... ...... ... ... .for inclusion of name in the
electoral roll in Form 8A has been accepted* / rejected*.

fu;e 264 [kkyh vtZ fLodkj.;kckcr fdaok ukdkj.;kckcr rikhyokj dkj.ks%

*

Detailed reasons for acceptance or rejection [under rule 26(4) ]

fBdk.k@ Place:
ernkj uksan.kh vf/kdk;kph lgh
fnukad@ Date:
Signature of Electoral Registration Officer
* udks vlysyk Ik;kZ; [kksMkok@Strike out the inappropriate alternative.

ernkj uksan.kh vf/kdk;kph eksgj

(Seal of the Electoral Registration Officer)