This document contains a form for claiming inclusion in the electoral roll for a Teachers' Constituency. It requests personal details like name, address, father's name, age, disability status if any, and whether registered as an elector elsewhere. It also requires educational qualifications and details of teaching experience of more than 3 years in the last 6 years. The applicant declares their citizenship and the truth of the details provided. It also contains sections for acknowledgment of receipt and intimation of acceptance or rejection.
This document contains a form for claiming inclusion in the electoral roll for a Teachers' Constituency. It requests personal details like name, address, father's name, age, disability status if any, and whether registered as an elector elsewhere. It also requires educational qualifications and details of teaching experience of more than 3 years in the last 6 years. The applicant declares their citizenship and the truth of the details provided. It also contains sections for acknowledgment of receipt and intimation of acceptance or rejection.
This document contains a form for claiming inclusion in the electoral roll for a Teachers' Constituency. It requests personal details like name, address, father's name, age, disability status if any, and whether registered as an elector elsewhere. It also requires educational qualifications and details of teaching experience of more than 3 years in the last 6 years. The applicant declares their citizenship and the truth of the details provided. It also contains sections for acknowledgment of receipt and intimation of acceptance or rejection.
This document contains a form for claiming inclusion in the electoral roll for a Teachers' Constituency. It requests personal details like name, address, father's name, age, disability status if any, and whether registered as an elector elsewhere. It also requires educational qualifications and details of teaching experience of more than 3 years in the last 6 years. The applicant declares their citizenship and the truth of the details provided. It also contains sections for acknowledgment of receipt and intimation of acceptance or rejection.
ELECTION COMMISSION OF INDIA Claim for inclusion of name in the electoral roll for a Teachers’ Constituency
SPACE FOR PASTING ONE
RECENT UNSIGNED PASSPORT SIZE COLOR PHOTOGRAPH (4.5 CM X To, 3.5 CM) SHOWING FRONTAL VIEW OF FULL The Electoral Registration Officer, FACE WITH WHITE BACKGROUND .................................................................................( Teachers') Constituency
Sir, I request that my name be registered in the electoral roll for the.........................................(Teachers') Constituency.
1. The particulars are:-
Full Name
Sex ....................................... Father's/Mother's/Husband's Name (in full)
House Address (Place of ordinary residence)
House/Building/Apartment No. Street/ Mohalla
Town/Village Post Office Police Station/Tehsil/Taluqa/Mouza District State
Age Years Months Date of Birth d d / m m / y y y y
Visual impairment Speech & hearing disability Locomotor disability Other
Whether registered as an elector for any assembly constituency ...............................................................
If yes, then mention the following--- (a) Number and Name of the Assembly constituency.......................................................
(b) Part/Polling Station No.(if known)..............................................................................
(c) Date of Birth d d / m m / y y y y
(d) EPIC Number (if any).....................................................
Aadhaar Details:- (Please tick the appropriate box) (a) Aadhaar Number or
(b) I am not able to furnish my Aadhaar Number because I don't have Aadhaar Number Contact Number :- Mobile No. (optional)
Landline Email Id (if any)....................................................................................
2. During the last six years I have been engaged in teaching for a total period of more than three years as follows:- Name of Educational Institution From (Date) To (Date) Period 1. 2. 3. 4.
In support of the above I submit herewith……………………………………………………………….
……………………………………………………………………………………………………………… …………………………………………….………………………………………………………………… ………………………………………………………………………………………….…………………… 3. * My name has not been included in the electoral roll for this or any other teachers’ constituency. Or * My name has been included in the electoral roll for the........................................teachers' constituency under the address given below and I request that it be deleted from that roll :-
4. I declare that I am a citizen of India and that all the particulars given above are true to the best of my knowledge and belief.
Place.................................... Date..................................... ___________________ Signature of claimant
NOTE : Any person who makes a statement or declaration which is false and which he either knows or believes to be false or does not believe to be true is punishable under section 31 of the Representation of the People Act, 1950.
The application in Form 19 of Shri/Smt./Kumari................................................................................................
address............................................................................Has been— (a) accepted and the name of Shri/Smt./Kumari.........................................................................has been registered at Serial No........................in Part No....................................... (b) rejected for the reason........................……………………..………………………………………
Certificate of Head of Institution of an Educational Institution
specified by the State Government under clause (b) of sub-section (3) of section 27 of Representation of the People Act, 1950.
This is to certify that Shri/Smt/Kum. ______________________ has been
teaching in ___________________ (name of the institution) for a total period of three years within the last preceding six years as shown below against a post on regular/adhoc/contract* basis with specified scale of pay of Rs. _____________/Consolidated pay.
1. (a) * As per the records of the Institution, he/she has been engaged in this institution continuously from _______ (date) to _______ (date), without any break.
OR
(b) * as per the records of the Institution, he/she has been engaged in this institution for the following period of service :-
From _______ to _______
From _______ to _______ From _______ to _______
2. The dates of commencement of service and retirement of the teacher :
a. The dates of commencement of service: b. The date of retirement.
(Signature, Name and Seal of the Head of Institution)
