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Get IN ECI-EPIC-002

FORM ID ECI-EPIC-002 Election Commission of India Application for issue of Duplicate Elector s Photo Identity Card EPIC State/Ut S-25 AC NO. Name District Campaign ID WB -2000-01 Elector s Particulars To be filled by Elector A B To Sir/ Madam I request that a Duplicate Electoral Photo Identity Card be issued to me as my original card is lost/ destroyed /mutilated* 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 The Electoral Registration Officer Assembly /Parliamentary Constituency 1. Name of Elector 2. EPIC No of original Card 3. Father s/ Mother s / Husband s Name 4. Sex M/F 6. Address i House / Door Number ii Street/ Mohalla / Road / Gali iii Area / Locality iv Town/ Village vi Police Station viii Reasons for applying for a Duplicate card 5. Age Years as on 1st Jan 200. v PIN CODE ix Tick 3 the appropriate box I hereby return my mutilated card. Date Thumb Impression Place Or Signature of Elector I undertake to return the earlier card issued to me if the same is recovered at a later date. C Authentication for Issue of EPIC To be filled by ERO s Representative Part No Register NO. Verified by Date //2000 D Serial No* of Elector in Part Serial No* in Register Signature Designated Photography Location DPL No Field Unit No* Personal ID No* PIN Token No* or Receipt No* EPIC Details To be filled by the Photography Team EPIC Mode Tick 3 appropriate box On-line Date of Photography //200 EPIC No* Off-line Preparing EPIC Tick 3 appropriate box when complete Editing of Data Authorised issue of EPIC Date of Issue Printout Lamination E of ERO s Rep* Acknowledgement of Duplicate EPIC by the Elector Received Duplicate EPIC on Date Elector s Signature - Strike out the inappropriate alternative. Name District Campaign ID WB -2000-01 Elector s Particulars To be filled by Elector A B To Sir/ Madam I request that a Duplicate Electoral Photo Identity Card be issued to me as my original card is lost/ destroyed /mutilated* 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 The Electoral Registration Officer Assembly /Parliamentary Constituency 1. Particulars in support of my claim for issue of duplicate EPIC are given below The Electoral Registration Officer Assembly /Parliamentary Constituency 1. Name of Elector 2. EPIC No of original Card 3. Father s/ Mother s / Husband s Name 4. Sex M/F 6. Address i House / Door Number ii Street/ Mohalla / Road / Gali iii Area / Locality iv Town/ Village vi Police Station viii Reasons for applying for a Duplicate card 5. Name of Elector 2. EPIC No of original Card 3. Father s/ Mother s / Husband s Name 4. Sex M/F 6. Address i House / Door Number ii Street/ Mohalla / Road / Gali iii Area / Locality iv Town/ Village vi Police Station viii Reasons for applying for a Duplicate card 5. Age Years as on 1st Jan 200. v PIN CODE ix Tick 3 the appropriate box I hereby return my mutilated card. .

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