Post on 11-May-2023
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CERTIFICATE
"This is to certify that Stri/Smt/Km.------- -----has
been teaching in---------- ( name of the institution) for a total period of three years
within the last preceding six years against a sanction post on regular /ad-hoc**basis.
2. (a) **As per the records of the institution, He/She has been engaged in this institution continuously
from -----(date) to-*---(date)
OR
(b)** As per the records of the institution, He/She has been engaged in this institution for the
following periods of service;-
From-------------to-------
From-------------to---------------
From-------------to---------------
(Signature, Name & Seal of the Head Iinstitution)
(**strike out whichever is not applicable )
fl['
Annexure-B
PREPARATION OF ELECTORAL ROLLS OF NAGPUR DIVISION TEACHERS'
CONSTITUENCY OF MAHARASHTRA LEGISLATIVE COUNCILUnder section 21(1) of the Representation of People Act, 1950
Notice under rule 31(3) of the Registration of Electors Rules, 1960
In pursuance of rule 3 1(3) of the Registration of Electors Rules, 1960 each of the Electoral Registration officers
whose particulars upp*i in the rihsr SCHEDULE below hereby calls upon every person entitled to be
registered in the electoral roll of the constituency mentioned in the said schedule to send to or deliver at his
office, on or before S.r, Novemb er 2016 at the latest, an application in Form 19 appended to the Registration of
Electors Rules, 1960 and reproduced in the Second Schedule below, for inclusion of his/her name'
2, The applications may also be sent to the Assistant Electoral Registration Officers/ Designated Officers
whose particulars are shown in the FIRST SCHEDULE'
As the electoral rolls for the Teacher's Constituencies are required to be prepared afresh every time before an
election, all persons'whose names are included in the existing electoral rolls for these constituencies should
also submitfresh applications in the prescribedform'
3. eualifications:- Every person who is citizen of India, and is ordinarily resident'in the constituency and
has, within the six yeurs irn*ediately before 1't Novemb err2016, been engaged for a total period of at least-three
years in teaching in any of the educational institutions, within the State specified to be not lower in standard than
that of a Secondary school is eligible to be included in the electoral roll. The list of Educational Institutions so
specified is available with the officers mentioned in the First Schedule.
4. Every application in the Form 19 by person seeking enrolment in Teachers'Constituency shall be
accompanied by a certificate from the head of EducFational Institution certif,ing the engagement of the person
concerned as a teacher for a total period of three years within the last preceding six years. The format for the
certificate will be as follows:-CERTIFICATE
"This is to certifu that Shri/SmVKm.-------_has been teaching in------------ ( name of the institution) for a total period of
three years withinJhe last preceding six years against a sanction post on regular /ad-hoc**basis'
2. (a) **As per the records of the institution, He/She has been engaged in this institution continuously
from -----(date) to------(date)OR(b)** As per the records of the institution, He/She has been engaged in this institution for the
following periods of service;-
From-------------to-------From-------------to-------From-------------to-------
(Signature, Name & Seal of the Head
linstitution)(**Strike out whichever is not applicable )
6.plication' the Certificate should be
signed by the Head of the [nstitution, in wliich he last served..1. Applications in bulk whether submitted in person or by post, shall not be considered for inclusion by the
ERo. However, the Head of the Institutions may ftrward the applications ofall his staff together' one member
of a family may also submit the Form 19 of other members of the same family and may get the certificate
verified by producing original certificates in respect of each member.
g. It should be noted that any person who makes a Statement or declaration in the application which is false
and which he either knows or believes to be false, or does not believe to be true will be punishable under Section
31 ofthe Representation of People Act, 1950'g. printed applications of Form 19 may be obtained from the offices of ERo/AERo/Designated officers or
Manuscript, typewritten, cyclostyled or privately printed forms will also be accepted'
ffli
SECOND SCHEDULEFORM 19(See rule 31)
Claim for inclusion of name in the electoral roll for a Teachers' Constituencyl$,'lr
To
Tff"TTT?l.H?:ffi:T,O#;;;1",,,Sir'
I request that my name be registered in the electoral roll for the------------- (Teachers)' Constituency. The particulars are: -Name (in full),--- ----------Sex------------
Father' s/Mother's/Husband's name (in full)House address (Place of Ordinary residence)House No. --------Street/Mohalla --------Toun/Village ----------Post OfficePolice Station/Tehsil/Taluka/MouzaDistrict
2. During the last six years I have been engaged in teaching for a total period of more than threefollas rollows :-
Name of Educational Institution From (Date) To (Date) Period
I2.
-r.
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 citizen of India and that all the particulars given above are true to the best ofmy knowledge and belief.
Place-------Date--------
Signature of ClaimantNOTE:- 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.* Strike out the paragraph not applicable.
Additional information
Please paste a
photograph of the
elector applicant
here
l.Name of the elector aPPlicant
2.F ather' s lMother' s name
3.(a) Whether registered as elector for any assembly constituency -YesA{o(b) if yes mention the following perticulars
(i) Number ane Name of LAC(ii) partlpolling stationNumber (if known)(iii) Date of birth(iv) EPIC number (if anY)
(v) Contact No(vi) Email Adress (if anY)
Mobile
Signature of elector aPPlicant
Perforation...
INTIMATION OF ACTION TAKEN
The application in Form 19 of Shri/Shrimati/Kumari
address----- has been registered at Serail No'---------
in part no. ---------
(a) accepted and the name of Shri/Shrimati/Kumari----------
has been registered at Serial No.--------- in part no'---------
(b) rejected for the reason--------
Date:-(Address)--
Electoral Re gistration Offi cer
(Address).
- -- - - -- (P erforation) - - -- -
ReceiPt for APPlication
Received the application in Form 19 from Shri/Shrimati/Kumari*------------
Address {< -----------
Date:-
(Address)--
Electoral Registration Offi cer