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/-, I/ /'.I? NOMTNATION PAPER
Be*fi\sra2
s*o -^r' K,,Kffiq:fr$d'e
Assembb'of Ne$

A.

STRIKE OFF PART I OR PART II BELOW WHICHEVER IS NOT APPLICABLE

PART I
(To be used b1 candidate set up b1'recognised political party)

I norninate as a candidate lor election to the Legislative Assembll' fronr

:
t?.1.?. .14. ? ! 9.rc (!.€t #
*Jm b t, C o n st tu e n c 1
i .

candidate's,rurn ....MA.MATA IZAAIEI(.TE-E ..Father's/ria@ert/hus&qndb

6i;a(qf€
o-orrr, uddi.s,
Rl.9l. c_HA.rrF(rEE-
3_oB: Hl
"^,"ff_ir*!liiiiA
riRd.f.T..r..lSg?.K41!1. .:..29e.9.%.
9. .......His name is enrered at Sl.
xo.J.67....in parrxo..?9.f.....of tlie electoral roll for (€.1.[3nau.vt.rPu.R66^tEf€$A.ssernbli'
constituencl,.
IVh nanre is ...(\:lAtlADEA....AAq .......and it is entered at Sl. No. .l.a'3....invu't
Xo...i/..*-.....of the electoralroll for theRlo./:la^!Dtq&1C(qF{.{,./ol-)Assenrbll constituencl'.

ou,. ic,oit,pol,t ,[:":h;,,,F-r$l1

PART II
We hereb-v- nominate as candidate for election the Legislative Assernbll' frorn

Candidate's name........... Father's/m other's/husband's

name.......... .His postal
1...............His name is entered at Sl.
 in
We declare that we are electors of this Assembly constituency at /out nalnes at'e entered
the electoral roll for tliis Assembly constituency as indicated atrd we append our
/elow
signatures below in token of subscribing to this nomination:
/
Particulars of the proposers and their siAnatures
S1.no. Elector Ro11No. of ProPoser Fuil Naz Signature Date
Part No. of S.No. in that part
Electoral Roll
2 J 4t 5 6
1

I/
2./
3. /
4/ /
5.
6/
7/
8/
e. /
/
I0.
N R - There should be ten electors of the consliruellcy as proposers

PART III
I, the candrdate mentioned in Part UPrt (Strike out which is not applicable) assent to
this nomination and hereby declare that-
(a) I arn a citizen of India an{ have not acquired the citizenship of any foreign State;
(b) that I have completed.. ..(6..'. V.u., of ug.;
-ffi.#6to
[sTzuKE OUT c(i) OR c(ii) BELOW WHICF.TEVER IS NOT APPLICAELE]
(c) (i) I am ser up ar rhis .r".,ion Tu'"ff&'fl'*fi;tfGffiognised
National pariy/S+e+e+e**y in this State and that the symbol reseled for the above
party be allotted to me.
OR t
(iD I am ser up at this election by the.... / ...............par1y, which is a
registered unrecognised political partylthat y' atn contesting this election as an
independent candidate. (Strike out which is/not appiicable) and that the symbols I
have chosen, in order of prefet'encc, arc. j
(i) .. .. . (ii) ...'..
......../....- .... '. (iii)
(d) my narne and my father's/ree+heps/hr*s'bend* name have been correctly spelt out
above in........flN.fiU.€.H.... (name of the language); and
(e) That to the best nf',ry knowledge and belief, I am qualified arrd not also disqualified
for being chosen to fillthe seat in the Legislative Assembly of this State.
* I furllrer declare that I am a member of the..../.... Caste/tribe which is a scheduled
**caste/tribe of the Statc of........... .............in.1e1ation to............................(area) in that State.

2
 I also declare that I have not been, and shall not be nominated as a candidate at the present
s;eneral election/tlru{4rerchrtium being held simultaneously, to the Legislative Assembly
xlesr B ed.qA* of (State) from more than two Assembly constituencies.

out"lQ:0J
'$Q:?uL
* Score out this paragraph, ifnot appllcable.
** Score out the $'ords not applicable.

N.B.-A "recognised poiitrcal pary"' means a political parg recognised b1 the Electron Commission under the Electiou Syrbols (Resenation

and Allotment) Olcjer. 1 968 in the State concerned

PART IIIA
(To be lllled b1' the candidate)
(I ) Whether the candidate-
(i) has been convicted-
(a) ofany offence(s) under sub-section (l); or
(b) for contravention of any law specified in sub-section (2)
of section 8 of the Representation of the People Act, 1951 Jee'/No
(43 of 1951): or
(ii) has been ccnvicted for any other offence(s) for which he has been
sentenced to imprisontnent for two years or more.

If the answer is "Yes", the candidate shall furnish the following information:

iii) potir. station(s)d9?i .ApPuoaorstrict(s)ltf lW.f*...State(s). .t:/.er..nilu.q.G6

(iii) Section(s) of the concemed Act(s) and brief description of the offence(s) tbr '"''hrch
he has been convicted ... .tl.g.f....n.eP.LtC4At*.....
(iv) Date(s) of conviction(s). 4r/4 7. . . A P. P.H C4 g,E
.

(v) Court(s) which convicted the candidat e. . . . .d.Of . . . $tpPtt. 94.G L€,.
(vi) Punishment(s) imposed [indicate period of imprisonment(s) and/or quantam of
fine(s)l ..N0.tr. AroF u ee&tj
(vii) Date(s) of release from prison ... ... .rr/.o.f. ... tMPLt.€A&#..... ...
(viii) Was/were any appeal(s)/revision(s) filed against above conviction(s). ...iFedNo
(ix) Date and particulars of the appeal(s)/application(s) for revision filed ... .. .C'!.qf .. ...
.At*ucegt$...
(x) Name of the court(s) before which the appeal(s)/application(s) for revision
filed... ..r{.0r... . A.tr-q4.ca &.14
(xi) Whether the said appeal(s)/application(s) for revision haslhave been disposed of or
is/are pendi N.o7...Ml=t A Arc
"g..
(xii) Ifthe said appeal(s)/application(s) for revision has/have been disposed of--
(a) Date(s) of disposal. . . I'|.W. .AP..4.CAAIS..
(b) Nature of order(s) passed. ..NO.T. .. . .4.#.*l.gtgLE
 (2) Whether the candidate is holding any office of profit under the Govemment of India or
State Government?.......... (YeNo)
-lf Yes, details olthe offlce held.... . .^l9.T"..A.pP.uCeGU_...
(3) Whether the candidate has been declared insolvent by any Court?........... (rfes,Alo)
-If Yes, has he been discharged from insolvency. .r,l.O.f .ACQ.H.C4BG
(4) Whether the candidate is under allegiance or adherence to any foreign country?............. (yedNo)
-rf yes. give details. ....f:'l.qf .
ApP..+t.*fCLE..
(5) Whether the candidate has been disqualified under section 8A of the said Act bv an order of
the Presi dent?........... ({6s,,}.1o1
-lf Yes, the period for which <lisqualified.. f:/gf...aepr: C4&LG
(6) Whether the candidate was dismissed for corrr.rption or for disloyalty while holding ofTice
under the Government of India or the Governrnent of any State?............. (rle:No)
-tf yes, the date of such dismissal. nf.gf_. 4r4U e4e(f
(7) Whether the candidate has any subsisting contract(s) with the Government either in individual
capacity or by trust or partnership in which the candidate has a share fbr supply of any goods
to that Government or for execution of works undertaken by that Government?.......... (yes,No)

-lf Yes. with which Government and details of subsisting contract(s). ..f.r/af....A.?p*tC,44tA
(8) whether the candidate is a managing agent, or manager or Secretary of any company or

Corporation (other than a cooperative society) in the capital of which the Central/ Government
or State Covernment has not less than twenty-five percent share?.............. (lrre#no)
-lf Yes. with which covernment and the details thereof. ..r^/.ar. 4ppuA.€.G....
(9) Whether the candidate has been disqualified by the Commission under section l0A ol tire said
Act...... (XesA.,lo)

-lf yes, the date of disqualification.. .N.p.f. .Q'opuea6cq

Llo.Ld)a-_,,,
Place:
Date:
piteea
^,l6wtpu<
PART IV
1ffi*h.W
Seriar No
or nom ination paper iillii]fl
:''K ).'"Ttl; 3f'-i'i)r-",,
This nomination was delivered to rne at m1, office at.2...C.:-j.. ,i:,:; un rg .i eri6/ui
the * candidateiproposer Qllame).

out.lO.'C3,pAU " Returni

*Score out the u,ord not applicable

?.1 n illzndioram Assefr

 Decision of Retrr_-:_^ n a- PART y
.::,".,r#1?".
:-:i,r?*'i,Titr't,r*:;u*q*,r*#,:*,t*:Tff

Date.......... ....

"...'(Perforation)...... ReturningOfficer