ANNEXURE – 1

GENERAL ELECTIONS TO LOK SABHA – 2019

Particulars of Departments / Undertakings / Local Bodies / Institutions PHOTO

1 (a) Name of the Department / Undertaking

(b) Code No. The Department
2 (a) Name of the Office / Institution
(b) Office Address
(c) Office Phone No. with STD Code
(d) Taluk Name
3 Whether State Government (SG) / Central
Government(CG)
4 (a) Whether Public Sector undertaking (YES / NO)
(b) Whether Central or State Government PSU
5 Whether Local Body ( Panchayat Union / Town
Panchayat / Municipality / Corporation)
6 If Education Institution, Whether
(a) College
(b) Higher Secondary / High School
(c) Elementary / Primary
(d) Other ( Non Teaching Staff)
Particulars of the Polling Personnel
7 Name of the Official
8 (i) Designation
(ii) Age
9 Sex ( M / F)
10 a. Level of Pay****
b. Applicable Cell****
11 Current Basic Pay****
12 Residential Details
i) Residential Address
ii) Nearest Police Station to the Residence
iii) Residence Phone No. with STD Code
iv) Cell Phone No.****
v) Native Taluk / District
13 No. & Name of the Assembly Constituency
i) Of Native Place
II) Of Place of Residence
III) Of Office Location
14 (a) No. & Name of the Parliamentary Constituency
(b) Assembly Constituency in which enrolled as Elector AC No: AC Name:
VOTER ID No.****
(c) Part No. in which enrolled
(d) Sl.No. in which enrolled
15 (i) Whether the official officiated in previous General (YES / NO)
Elections or Bye‐Elections
(ii) If yes furnish the details (2014 / 2016) etc., Polling
Station No. & Assembly Constituency No. etc.,
16 Whether the official has previous experience in (YES / NO)
handling EVMs
17 Whether the official has been disqualified or (YES / NO)
punished or reprimanded or transferred out by the
Election Commission of India
*****Mandatory

Signature of the Official

 ANNEXURE –III
GENERAL ELECTIONS TO LOK SABHA – 2019
Particulars of Departments / Undertakings / Local Bodies / Institutions
Abstract Details of Employees

1 (a) Name of the Department / Undertaking

(b) Code No. The Department

2 (a) Name of the Office / Institution

(b) Office Address

(c) Office Phone No. with STD Code

(d) Taluk Name

3 Whether State Government (SG) / Central

Government(CG)
4 (a) Whether Public Sector undertaking (YES / NO)

(b) Whether Central or State Government PSU

5 Whether Local Body ( Panchayat Union / Town

Panchayat / Municipality / Corporation)
6 If Education Institution, Whether

(a) College

(b) Higher Secondary / High School

(c) Elementary / Primary

(d) Other ( Non‐Teaching Staff)

Employees Details ‐ Abstract

Men Women Total

7 a) Total numbers of Employees in all Categories

b) Out of Column – (a) number of employees

exempted from polling duty as per Annexure ‐ II
c) Total Number of employees to whom particulars
are going to be sent in Annexure‐ I

Signature of the Head of the Office

/ Competent Authority