Election Commission of India

a njj Miza Application for issue of Replacement Electors Photo Identity Card (EPIC) khW thfhs ifgl milahs mil nfhU zg

FORM ID
got ID

ECI-EPIC-001

A B

m.

M.

State/UT / khy / a unjr : AC (No. & Name) / bjhF vQ bgaU : District / khtl : Electors Particulars (To be filled by Elector) / thfhs tuf (thfhsuh uggl
ntL)

To / bgWe

Sir / Madam / mah / mikp, I request that a Duplicate Electoral Photo Identity Card be issued to me as my original card is lost/destroyed/mutilated or due to change of address. I want to get a fresh card with my new address. I am returning my EPIC to you along with fee for issue of duplicate EPIC. My name is included in the electoral roll for the above constituency. Particulars in support of my claim for issue of duplicate EPIC are given below:
vDila fhzhk nghd / mJnghd / nrjkilj myJ Kft khw nkbfhsglntoa cikahd thfhs ifgl milahs milF gyhf khW thfhs ifgl milahs mil tHFkhW nfL bfhnw. vdJ a Kftl Toa khW thfhs ifgl milahs mil bgw Unw. eh vDila thfhs ifgl milahs milia kW khW thfhs ifgl milahs mil tHFtjfhd flzij brYJnw. vDila bgauhdJ nkFl rlkw bjhFF cgl thfhs goa lbgWsJ. khW thfhs ifgl milahs mil tHFtjfhd vDila zgfhd fhQ Mjhufis rknw.

The Electoral Registration Officer / thfhs g mfh, Assembly / Parliamentary Constituency /

rlkw bjhF / ghuhSkw bjhF

1. Name of Elector / thfhs bga:

2. EPIC No. of Original card (if known) /

cikahd thfhs ifgl milahs mil v. (bjU) :-

3. Fathers / Mothers / Husbands Name / jij / jh / fzt bga :

4. Sex (M/F) :
ghd (M / bg)

5. Date of Birth (DOB) If not known then Age in Years) as on 1st Jan, 201____......
wj nj. (bjahjgr 201... ... #dt 1 ehsW csgo taij MLf Fl)

6. Address / Kft (i) House / Door number / L / fjyf : (ii) Street / Mohalla / Road / Gali / bjU / gF / rhiy / Ul : (iii) Area / Locality / l / mikl : (iv) Town / Village / efu / uhk : (vi) Police Station / fht iya : (v) PIN CODE /
mr FpL v

(vii) District / khtl :

(viii) Reasons for applying for a Duplicate card / khW thfhs ifgl milahs milF
zgjfhd fhuz

Tick ( ) the appropriate box / ca fl ( ) Fl : 1. I will collect EPIC from VRC/CSC / eh vDila thfhs ifgl milahs milia
thfhs nrit ikanyh / bghJ nrit ikanyh bgW bfhnw

2. I wish to receive my EPIC by Post (self addressed and stamped envelope enclosed) / eh
mr _y vDila thfhs ifgl milahs milia bgW bfhnw. (Rayhrl kW mriy xlgl ciw izfgLsJ)

3. I will collect EPIC from BLO / eh vDila thfhs ifgl milahs milia thF
rhto iy mYtylUJ bgW bfhnw.

) Signature of the applicant

zgjhu ifbahg

Tick ( ) the appropriate box / ca fl ( ) Fl : I hereby return my mutilated / old card /

eh vDila nrjkilj / giHa milia Jl izJns..

Date / eh :

Place / l :

I undertake to return the earlier card issued to me if the same is recovered at a later date / eh vDila giHa thfhs
ifgl milahs milia tUfhy ilFgr mjid xgilJ Lnw vW cWanw.

For Official Use / mYtyf gaghoF kL C

. thfhs ifgl milahs mil tHFtjfhd rhW (thfhs g mfh uah ugglntL)

Authentication for Issue of EPIC (To be filled by EROs Representative) /

Part No. / ghf v. :

Serial No. of Elector in Part / mj

ghf thfhsuJ tir v. :

ID number of Designated Photography Location (DPL) or Common Service Centers (CSC) / Flgl
ifgl ika (m) bghJ nrit ika milahs v. :

# Token No. or Receipt No. /

# nlhf v (m) uJ v.

Register No. /
gntL v.

Serial No. in Register /

gnto tir v.

Verified by: /
rghfglJ

Signature / ifbahg
Date / eh : ___/___/201___

D
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Acknowledgement of R- EPIC by the Elector / khW thfhs ifgl milahs mil

bgW bfhljfhd thfhs xif

Received Duplicate EPIC on (Date) / khW thfhs ifgl milahs mil bgWbfhsgl nj : 201___

Electors Signature Or Thumb Impression /

thfhs ifbahg (m) lJif bgUu nuif