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Nstituency: I. Applicant s particulars II. 1. Applicant s Name: 2. Father s/Mother s/Husband s Name: 3. Place of Ordinary Residence (Full Address): House/ Door No: Road/Locality/ Mohalla: Town/Village: Municipality/Ward No: Block/Gram Panchayat: Police Station: Post Office: Pin Code: District: Elector s Particulars as per Draft/Finally Published Electoral Roll, 200 (To be filled by ERO s representative) Part No: Sl. No. No & Name of Section: House No. Address III. My dat.

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