eotrenioctene Nanay Submission Date 10-05-2025 FORM & (See Rules 13(3) and (26) of the Registration of Electors Rules, ona 1980) ELECTION COMMISSION OF (roe aiied by omnes) INDIA Voter Application Form for Shifting of Residence/Correction of Entries in Existing Electoral Roll / Replacement of EPIC / Marking of PwD No. and Name of Assembly Constituency No[_2e1 | Nome Asansol Uttar o- ip. goa are of Parlomentary Conainyen, — (SS SENT ee NST OS eS aso Shy —! (Name of the applicant- Gopal Roy ‘Aadhaer Details: (Please tick the appropriate Box) © [=] Aacnear Pret “Perel: cy amo ble to ush my Andhaar umber because dont have Anchor cme CECEEEEEC| Mobile No. of Father/Mother/Any other relative (availsbley §— [—[ [TPT TI_I_T—] Email d of Self (or) Email d of Father/Mother/Any other relative (f availabe) (@)_(eubmit application for (Fick any one of the fellowing) 1 = Shifting of Residence (on) L] Se [_] Issue of Replacement EPIC without correction (07) 1 Application for Shifting of Residence have shifted my residence and I request that my name may be deleted from the previous address and shifted to the current address, "ement EPIC may be issued to me due to change in my address. | hereby return my old EPIC. mentioned b Prosent ing/Apartmerft_ Deviok Stroct/Area/Locality/ Utarayan Gopaipur | Ordinary tment arc Mohalla/Road eT Conroe Residence(Fit! Ror Fist no-3 Post UG Danga [gr err Address) | coracenras sonic Teh «d@opalpur Uttarayan | Crareraa lacanssexrrer [Samer bar sre-3 Jat [West Bengal Town/Village] Asansol | sree Self-ottested copy of address proof either in the name of applicant or anyone of the parents/spouse/edult child, If fs elector at the same address (Attach any one of the documents mentioned below = +f] aterteceny ofr nat are 2 SI] Asahaar cara yea!) Bank/Post oMice Revenue Departments Land Owning records ©. [] Registered Rent Lease Deed (In case of tenant) Including kisan Baht F] Sermosesbook or tetonaunedrecnedies 4. [7] indian Passport 7, [-] Reaistered Sale Dosdiin case of own house) Any Other (PL. Specity)Please correct my following details n Electoral Roll/EPIC: (Maximum of 4 enirles/particulars can be corrected) (Puta tick ~~ Snbspin appropriate box below) SPAGE FOR Copy of selhattested Documentary Proof in support of claim tobe attached. PASTING ONE 1 E] Neme 2 Gender a Dosage RECENT PASSPORT Nae 8. Relation ° Address eel Type Name UNSIGNED 7 | Mobile 8 Photo cotor Number PHOTOGRAPH (asemxas Je correct particulars in the entry to be corrected are as under:- cM) “The correct particulars in the enty tobe corrected m OM) . FRONTAL 2 VIEW oF FULL FACE WITH wire Name of Document in support of above claim attached BACKGROUND a Conwy ie b. PHOTO TOBE ° CHANGED) | request that a replacement EPIC may be Issued to me due to change in my personal details I hereby return my old EPIC. 3. Application for lssue of Replacement EPIC without correction request that a replacement EPIC may be lesued to me ae my original EPIC Ie- (uta tick in appropriate box ) 1 ED tose 2 Destroyed due ta reason beyond contrl ike floods, fre, other natural disaster ete. 3.) Mutilatea I nereby return my mirtilated/ old EPIC (OR)! have attached copy of FIR/Police report for lost EPIC & | undertake to return the earlier EPIC iseued to me ifthe same is recovered ata later stage. - Application for Marking Person with Disability Category of disability (Tick the appropriate box for category of disabilty) Locomotive [| Visual Deat & any other (Give description) Dumb Percentage of % Cemificate attached (Tiek the Yes | No disability appropriate box) DECLARATION | HEREBY DECLARE that to the best of my knowledge and belief that | am a citizen of India and | am aware that making a statement or declaration which is false and which | know or believe to be false or do not believe to be true, Is punishable under Section 31 of Representation of the People Act,1950 (43 of 1950) with imprisonment for @ ‘term which may extend to one year or with fine or with both. Date: 10-05-2025 Place: Asansol ‘Accessibility Instructions. In the light of provisions of Rights of Persons with Disabilities Act 2016 and Rights of Persons with Disables Rules, 2017, In case of persons with intellectual disability, autism, cerebral palsy and multiple disabilities etc., signature CF left hand thumb impression of person with disability, or of signature of left hand thumb impression of his/her legal guardian will be required. * Submission of selfattested copy of mentioned documents will ensure speedy dk = =e ‘Acknowledgement/Recelpt for application == = Acknowledgement Number = $2528108W1005251200000 Date : 10-05-2025 Received the application in Form 8 of Shri/Smt/Ms. Gop: Roy Name/Signature of ERO/AERO/BLO st This Is a computer generated document and does not require signature ***