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Claim for inclusion of name in the electoral roll for a Graduates' Constituency

Applicant Photo: 

To, The Electoral Registration Officer
*Graduates Constituency: 

Sir, I request that my name be included in the electoral roll for the above Graduates Constituency. Particulars in support of my claim for inclusion in the electoral roll are given below:

1. Applicant's Details:

Surname (if any):
ఇంటి పేరు:
*Relation Name:
Relation Surname(if any):
ఇంటి పేరు:
Date of birth:     Day:    Month:  Year:  Age:
Gender: Relation Type:
*Educational Qualification:

House Address(Place of ordinary residence):

*House/Door number:
*Town/ Village:   *Tehsil/ Taluka/ Mandal/ Thana:
*Street /Area /Locality /Mohalla /Road:
*Town/ Village:
*Post Office:
*Pin Code:

Details of AC & EPIC, If the applicant's name is included:

Ac No & Name:
EPIC No(ID CARD NO): Polling Station No.:
Sl.No in PS:


2.I am a graduate of the  university having passed the degree/diploma examination in the year (dd/mm/yyyy)                                                                                 


I am in possession of a diploma/cerificate in  which is a qualification equivalent to that of a gratuate of a univeristy in india  having passed examination for the diploma/certificate in the year  (dd/mm/yyyy)  

3. In support of my claim as being a graduate/in possession of the above diploma/certificate,I submit herewith above diploma/certificate
4.My name has not been included in the electoral roll for this or any other Graduates constituency;
                My name has been included in the electoral roll for Constituency       and District   under the given address below and I request that it to be deleted from that roll.
House No: Street/Mohalla:
Mobile No:
Email ID:  
5. I declare that I am citizen of India and that all the particulars given above are true to the best of my knowledge.