9|R / FORM 8

P| H / To,
H3d|3| 9H|41 HH4|1| / The Electoral Registration Officer
- H| PH| | H
- Assembly Constituency
H[|d/Sir,
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1. Hd4 4| 1 / Applicant's details
|H:
Name Surname (if any) :
39|H (d 4|( [ ):
1 H1| 4| H # /
Age as on 1st January # 4 / Years :
H " / Sex :
H7H 3 d 7|3 [ :
Surname (if any) :
39|H (d 4|( [ ):
Name :
|H:
II.
2.
P|H|73 : 3 H| |P 4| 1 (91| 93|) :
H4| / q|1 PE| : House / Door No. :
"H| / H / 413| / H|[~H| / 1|s :
414| / "| :
s|4O|| / Post Office :
9 4|s / Pin Code :
3[P|H/3|H4|/ HsH/|| : Tehsil /Taluka/Mandal/Thana :
3. H3d|3| 4 9|| 9[| 4|s 4| 1 (d P | H H | H7 | H H|1| [ )
HH|/ District :
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Application ID : ECIS240892013Form8159 W4 4| 18| / Receipt for application
Received the application in Form 8 of Shri/Shrimati/Kumari bhupendra kumar Address , 7
solanki,khandari,agra,CIVIL LINES,282002,SADAR
Date : |4 1H1|41 H9P1 4| H1 P Hd 9|3 41 |H |H HH4|1| 4 [13|H1
/
Signature of the officer receiving the application on behalf of the Electoral Registration Officer
H3d|3| 4 9|| 9[| 4|s PE| :
H3d|3| P| 4| H|" PE| / Part Number of electoral roll :
3P H|" 4| HH P. / Serial number in that part :
| H 4| |H / Name of the Constituency :
4. |4 4| H| |H| 9* 4| 1 : IV. Details of entries to be corrected :
|4 4 [13|H1 | H" 4| T| / Signature or thumb impression of the elector
1| : / Place
3|1|O : / Date :
R|| 8V| R B|R |4 41B 4 HV WB
Application ID :
ECIS240892013F
Email : Mobile :
[ B4R 13(1) W1 26 & ] / [See rules 13(1) and 26]
Application for correction to particulars entered in electoral roll
I request that entry relating to myself appearing in the electoral roll for the above Constituency is not correct and
it should be corrected. Correct particulars in support of my request are given below :
Date of Birth, if known
Particulars of place of ordinary residence (Full address)
Street / Area / Locality / Mohalla / Road :
Town / Village :
III. Details of Elector's Photo Identity Card (if issued, in this or some other Constituency)
Elector's Photo Identity Card Number :
*My Name/*Age/*Father's/Mother's/Husband's name/*Sex/*Address/*Electoral's Photo Identity Card Number may be
corrected in terms of information provided in this Form above.
H1| |H/H/93|/H|3|/93| 4| |H / H " / 93| / H3d|3| 9|| 9[| 4|s PE| P 9|H H 391
d| "( P| 4 HP|1 |4 4 H|9 1
089
Father RelationType :
02-10-1978
bhupendra kumar
sharma
89/174/1 725
7 solanki
khandari
agra
CIVIL LINES 282002
SADAR
agra
up/73/359/0162068
agra north
Agra
27-11-2013
sharma.bhoopendra@gmail.com 9358685666
M
omprakash
sharma
35 yr(s)
| : 9P 43 4| H| 9P| 1 d 3| [ | |4| 413| [ H| HPc [ | HP [ H|3| [ |
|P 413| [ 4 [ HPc [ | 3P4| Pc3| 91 |P [| 413|, H 93Hc HHH
1950(1950 4| 43) 4| 4| H|1| 31 4 HH| d s| [ 1
4|4 |#| 4| 1H / Details of action taken
(B|VB H 4 R|| 9H|41H N04|1| q|1| R1| H|4B|)
(To be filled by Electoral Registration Officer of the constituency)
|/|H3|/4 H|1| 4| Hd H3d|3| P| H 9* 4| |4 41 4 H9 9|H -8 H 1|4|1* / H1|4 3*
41 d| "| [ 1
The application of Shri/Smt./Km.bhupendra kumar for inclusion of name in the electoral roll in Form 8 has been accepted* /
rejected*.
Detailed reasons for * acceptance [under or in pursuance of rule 18*/20*/26(4)] or *rejection [under or in pursuance of rule
17*/20*/26(4)] :
Place :
Date : Signature of Electoral Registration officer Seal of the Electoral Registration officer
(9|Fs HH N04|1| 4| 9H| 4|VHW, 9B|R N04|1|, 94 H4 N04|1|) / Remarks of Field Level
Officer (e.g. BLO, Designated Officer, Supervisory Officer.)
Note - 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).