Editable Enumeration Form

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Date of Birth

Mobile No.

Aadhaar No. (Optional)

Father / Guardian Name

Father / Guardian EPIC

Mother Name

Mother EPIC

Spouse Name

Spouse EPIC

Current Roll Elector Name

Current EPIC

Current Relative Name

Current Relationship

Current District

Current State

Current AC Name

Current AC Number

Current Part No.

Current Sr. No.

Old SIR Name

Old SIR EPIC

Old SIR Relative Name

Old SIR Relationship

Old SIR District

Old SIR State

Old SIR AC Name

Old SIR AC Number

Old SIR Part No.

Old SIR Sr. No.

Upload Current Photo

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Declarations Declaration 1 Declaration 2 Declaration 3

Signature Name / Self

Signature Date

Annexure-III

Enumeration Form

Name and contact No of BLO (pre-printed)

Elector’s Name,
EPIC, Address
(Pre-printed).

Serial No., Part
No. & name,
AC/PC Name,
State
(Pre-printed).

QR Code

Old Photo
(Pre-printed)

Paste Current
Photo

Date of Birth (DD/MM/YYYY)
Aadhaar No. (Optional)
Mobile No.
Father’s/Guardian’s Name
Father’s/Guardian’s EPIC No. (if available)
Mother’s Name
Mother’s EPIC No. (if available)
Spouse’s Name (if applicable)
Spouse’s EPIC No. (if available)

Details of the Elector in the Electoral Roll of the last SIR

Details of the Relative, whose name is given in the previous column, in the last SIR

Elector Name:

Name:

EPIC No. (if available)

Relative’s Name:

Relationship:

District:

State:

AC Name:

AC Number	Part No.	Sr No.

AC Number	Part No.	Sr No.

(i) The elector mentioned above, being myself/my family member, has not acquired the citizenship of any other country.

(ii) I am applying for inclusion in the Electoral Roll, and the name mentioned above, being myself/ my family member, is not included in any other Assembly Constituency/ Parliamentary Constituency.

(iii) I am aware that making the above statement or declaration in relation to this application which is false and which I 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 a term which may extend to one year or with fine or with both.

Signature/Left Thumb Impression of Elector or
Any Adult Family Member (mention relationship) with date

BLO’s undertaking: I have verified the above details from the electoral roll(s) of the last SIR.

BLO’s Signature