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‫رم‬ ‫ا‬ ‫اروں‬ ‫ا‬ ٔ ‫ا‬ 2019 ( ‫اہ‬ )‫ا ف‬ ‫ن‬

‫۔‬ ‫ر‬ ‫ات‬ ‫جذ‬

ٔ
‫ا ف‬ ‫ن‬ ‫( م‬Demand Draft) ‫ا‬ ‫( ڈ‬Pay Order) ‫آر‬ ‫( رو‬RS.50,000/-) ،‫ ار‬50 ٔ .1
ٔ
‫ا ۔‬

‫ار ل د ۔‬ ٔ ٔ ‫د‬ ‫رم‬ (Demand Draft) ‫ا‬ ‫( ڈ‬Pay order) ‫آر‬ ‫ اس‬.2

‫۔‬ ‫ل‬ ‫۔ ر‬ ‫ل‬ ‫رت‬ (Demand Draft) ‫ا‬ ‫( ڈ‬Pay order) ‫آر‬ ‫ف‬ ! ‫ د ر‬.3

‫ۓ ۔‬ ‫ہ ر وا‬ .4

‫د ۔‬ ‫د‬ ‫ا‬ ‫ں‬ ‫د‬ ‫۔ اس د‬ ‫ رم‬.5

‫ار ل د ۔‬ ‫وس ج ذ د واز ات‬ ‫ر‬ ‫ر ڈا‬ ‫ رم‬.6

‫و‬ ٔ ‫رٹ‬ ‫( ر‬03) .1

(Demand Draft) ‫ا‬ ‫( ڈ‬Pay order) ‫آر‬ ‫ ا‬.2

‫رڈ‬ ‫ ا‬.3

: ‫رم ار ل‬

To,
Col, Aman Ullah
Pakistan Tehreek-e-Insaf Central Office
1st Floor, Fortune Plaza (Savor Building)
72, East Blue Area Islamabad
Contact #: 0336 3000789
Pakistan Tehreek-e-Insaf
Application Form
Application No: _______

For Merged FATA (KPK Province)


1. PERSONAL INFORMATION
Name
Date of Birth Gender: Male Female
CNIC 3 Colored Passport size
Mobile No. pictures
Landline No.
Father/Husband Name
Email
Present Address
Permanent Address
District Province
In which constituency is your vote
registered
Education/Qualification/Certification
2.WORK / PROFESSIONAL HISTORY-List your employment/ business history, recent two
Company/Business Name Position Date

3. GOVERNMENT SERVICE, if any-skip if you have not been employed by Government(last 2)


Department Position Date
From:
To:
From:
To:
4. NAME OF POLITICAL PARTIES YOU WERE ASSOCIATED WITH PREVIOUSLY
Name of political party / parties & position held, if any Date
From:
Party 1
To:
From:
Party 2
To:
From:
Party 3
To:
5.1HAVE YOU EVER BEEN AWARDED RESERVED SEAT? Yes No
Party name & position Reserved Seat Date
From:
To:
From:
To:
From:
To:
5.2 PREVIOUS ELECTION CONTESTED Yes No
Level: Local Government, provincial Assembly, National Assembly, Senate, None
Year of Level Constituency Name & No. Won / Vote Significant Positions/Ministries
Election Lost Received Held
6. Declaration (Please attach additional pages if you need to write more details for any of the declarations)
S. No Declarations Response
6.1 I confirm that, I don't have dual nationality Yes No
6.2 Are you presently employed by any organization inside or outside Pakistan? Yes No
Details:

6.3 Do you or your wife and Children have properties outside Pakistan? Yes No
Details:

6.4 Has your name ever appeared on the State Bank of Pakistan's list of defaulter? Yes No
Details:

Have you ever in the past, applied for writing-off a loan from any bank inside or outside
6.5 Yes No
Pakistan?
Details:

6.6 Are you an active tax filer with FBR? Yes No

Have you declared all your assets and liabilities inside and outside Pakistan in filing to
6.7 Yes No
FBR?
Do you have any criminal or bankruptcy convictions from the courts in Pakistan or
6.8 Yes No
outside Pakistan or pending any case against you?
Details:

6.9 Have you ever been dismissed from government employment on charges of corruption? Yes No
Details:
7. Why do you think, you are the most suitable candidate for this seat.

8. Applicant's declaration

Pakistan Tehreek-e-Insaf (PTI) reserve the right at any time to check on any experience,
achievements, qualifications and skills claimed by you on your application form and on any
information provided by you in support of your application. By signing this form you will be
providing us with your agreement for us to proceed with this course of action.
a. I declare that to the best of my knowledge and belief, all particulars I have given as part
of my application for approval as a PTI Parliamentary Candidate are complete and true.
b. I declare that I will sign and keep up to date all personal and financial declarations as required. c.
I declare that I will abide by the code of conduct for Pakistan Tehreek-e-Insaf's Parliamentary
Candidate.
d. I delare that I have read the elgibility criteria and personal disclosure information, and that I
have notified the Parliamentary board's office of all relevent information as required.
e. I declare that I will in the future notify the Parliamentary board's office of any change in
circumstances in relation to eligibility criteria and disclosure information
f. I declare that I have read and understood the declaration and oath section of the new
nomination form of Election Commission of Pakistan (ECP), which reads as follows:-

"I have consented to my nomination and that I fulfill the qualifications specified in Article 62
of the Constitution and I am not subject to any of the dis-qualifications specified in Article 63
of the Constitution or any other law for the time being in force for being elected as a member
of the National Assembly / Provincial Assembly."
g. I understand that any false declaration or misleading statement or any significant omission
in the information I provide may constitute prima facie grounds for my removal from the list
of approved candidates and if elected to Parliament, may result in the nomination / seat
being withdrawn, and may lead to expulsion from the party.

Applicant Name Signature Date

9. Check List
Please make sure you have attached following documents:-

3 Passport size colored pictures


Original Deposit Slip
Copy of Pay Order / Demand Draft
Copy of CNIC
10. OFFICIAL-TO BE FILLED BY REGONAL OFFICE

Rank:(1 - 3)__________________
Name & Signature of Regional President
Date
CNIC#
11. OFFICIAL- ACTION BY CENTRAL PARLIAMENTARY BOARD
The Parliamentary Board will select the candidate on the following criteria:-
A How will you rank the applicant on personal integrity i.e degree of honesty, Score (1 - 10)
adherence to principles and ethics with clear standards of what is right or wrong
and enjoying good social standing in the community;

B How will you rank the applicant on his/her commitment & loyalty to PTI, Score (1 - 10)
i.e. length of membership with PTI, loyalty to its cause and adherence to PTI's
ideology and values;
Score (1 - 10)
C How will you rate the chances of this candidate winning the seat he/she has
applied for in the given constituency;

Total score: 30 Total score obtained:__________________

Selected Not Selected Stand By Others_____________

Name & Signature of Chairman CPB________________________ Date________________

Name & Signature of Secretary CPB________________________ Date________________

Please submit this form to Central Office on below mentioned address, for further quires please
contact Col. Amanullah, Chief of Staff to Secretary General
+92 336 3000 789

ADDRESS:
Col, Aman Ullah
Pakistan Tehreek-e-Insaf Central Office
1st Floor, Fortune Plaza (Savor Building)
72, East Blue Area Islamabad
Contact #: 0336 3000789