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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