R. KJ,. (* Proposer Date: 25-03-2019 Signature Of
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J F0lt\{ 2A (See RLl,E 4) NOMINATION PAPER f(. rJ o Election to the House of the PeoPlc ?- '. q.r 0 FVn n .L!-13 Itl RO S IRIKE OFF PART I OR PART II BELO W WIIICHEVER IS NOT APPI I('AI]I I PART I (To be used by candidate set up by recognized political party) I nominate as a candidate for election to the House of the People ftom the Not Applicahlc ['arl iamentary ConstituencY. Candidate's name .......NA......, Father's name ..........Not Applicable............ His postal address ...............Not Applicable His ,rame is entered at S.No ...NA... in Part No ...NA... of the electoral roll fbr ...NA . .. ....NA..... (Assembly constituency comprised within) ...NA... Parliamentary Constitucrrcr'. NIvNameis ......NA.....' anditisenteredatS.No....NA"' inPartNo""NA"' ofthe' clectoral roll for ...NA... *(Assembly Constituency comprised within) ...NA... Parliantt'tl i.r i' Constitr rency. Y R. KJ,. (* Proposer Date: 25-03-2019 Signature of -l- t ARl-it (To be used by candidate NOT set up by recognized political party) we hereby nominate as candidate for election to the House of the people from the I l-Machilipatnam Parliamentary Constituency candidate's name Yarlagadda Rama Mohana Rao Father's Name (Late)yarlagadda Neelachalam. His postal address 191289-8., Chilakalapudi, Machilipatnam-521002 Krishna District, Andhra Pradesh. I {rs name is entered at S.No 747 inpartNo 42 of the electoral Roll for ?5 -Machilipatnam (Assembly constituerrcy corrprised within) I l-Machilipatnam l'ari i arnentary constituency. \\ e declare that we are electors of the above Parliamentary Constituency and our names arc .'ntered in the electoral roll for that Parliamentary Constituency as indicated below and w.e trppcnd r)ur signatures below in token of subscribing to this nomination. PARTICULARS OF THE PROPOSER AND THEIR SIGNATURE ; S.No Narne of Elector Roll Full Name I Signature Date , Component No.of Proposcr r Assembly I :Constituen I Part No.of S.N,r in Electoral rh i-I I Roll lt:r t I 2 J 4 5 6 7 75 N4achilipalnam D, 373 Y Krisluta l\lohan l.>c+ropn 7-i Machilipatnam .12 i7?. Y Charrdra Kumar Y-el"4L-lr^-- 75 Machilipatnam 12 520 R Raina Ra<r -i 75 Machi lipatnarn 42 KK*.7 Ion. 61.7 R Canesh fJabu R, ?"n*a-L *)" s .-' 75 Machilipatnarn .+l It1. 522 R Sontesrvara Rao 2 (l 5 Machilipatnam 12 l 6t)9 Il Srikrishna ?-' 6:-l, 2s 7.5 Nlachilipatnam 42 t /+ Y Gowthanr Kumar 1 Y ii 75 Machilipatnam -t-Y GJ{-.*,, 42 3 .l as an h 9 7,s Machilipatnam 42 N.lageswara 44rpffi^rP1aEralvs;E 35.1 P Rao 'zs 3 t0 7.5 Machilipatnam **- #+ &U+a-k* eoetaY LC (,\ ,1 N.B There should be l0 electors of the constituency as proposers. (6(w -2- Y PART-III I. thJCandidate mentioned in PART l/Part II (Strike out which is not applicable assent) to this nomination and hereby declare : - (a) That I am a citizen of India and have not acquired the citizenship of any foreign State / Country. (b) That I have completed 56 years ofage: ISTRIKE OUT c (i) OR c (ii) BELOW WHICH EVER IS NOT APPLICABLEI (c) (i) That I am set up at this election by the ...NA.., which is a recognized National Party ,/State Party in this state and that the symbol reserved for the above party be allotted to rne. OR (ii) That I am set up at this election by the Bahujan Maha Party, which is a registered unrecognized political party that I am contesting this election as an independent candidate (Strike our which is not applicable) and that the symbols I have chosen, in order preferencc are: RubbersfronP ghiP i1 Whistle ii) f+histle- Iii) :Alhisth d) That my name and my father's/mother's/husband's name have been correctly spelt out above in English; e) That to be best of my knowledge and belief, I am qualified and not also disqualified tbr being chosen to fill the seat in the House of the People. * *Caste/tribe + I turther declare that I am a member of the NA Which is a scheduled ** caste / tribe of the state of NA in Relation to NA .................(area) in that state I also declare that I have not been, and shall not be nominated as a candidate at the present general election / by - election being held simultaneously, to the House of the People fi'om more than two Parliamentary Constituencies. t 0.*\^Q* (Yarlagadda Rama Mohana Rao) l)ate 25-03-2019 Signature of Clandidate "Score out lhe vords" assembly constituency comprised within" in the case oJ'Jammu arul Kashmir Andaman and Nicobar Islands, Chandigarh , Dadra and Nagar Haveli , Daman and Diu and LakshadeeP. -j- * Score out this paragraph, if not applicable. ** Score out the words not applicable N.B.A"recognized political party" means a political party recognized by the Election Commission under the Election Symbols (Reservation and Allotment) Order, 1968 in the state concemed PART_IIIA (To be filled by the candidate) I ) Whether the candidate i) Has been convicted NO a) Ofany offence (s) under sub-section ( l) or NA b) For contravention ofany law spe,:ified in sub -.sections (2) ofsection 8 of the Representation of the People Act, l9-sl (43 of 1951) ; NA or ii) Has been convicted for any other off'ence (s) for which he has been sentenced to imprisonment fbr two ),ears or more. ---------------- NO If the answer is "Yes", the candidate shall fumish the following information. ii) Case / first information report No. / Nos NA ii) Potice Station NA District (s) NA State (s) NA iii) Section of the concemed Act(s) and brief description of the offence '(s) which he has been convicted NA iv)Date (s) of conviction (s) ...... NA r ) Clourl(s) which conr,icited the candidate......... NA ............ vi) Punishment(s) imposed {Indicate period of imprisonment and / or quantum of fine(s) ... ........NA ....... vii) Date(s) ofrelease from prison NA 'iii) Was were any appeal (s) revision (s) field against above conviction(s) ... NA ,l -4- fto-no ixl iiate and particulars ofappeal(s) application(s) for revision field ...... NA x) Name of the court(s) before which the appeal (s) application(s) for revision filed:.... NA xi) Whether the said appeal(s) application(s) for revision has have been disposed ofor is are pending NA xii) ll'the appeal(s) application(s) for revision has/have disposed of ... NA ...... a) Date(s) of disposal NA b) Nature of order's passed ...... NA 2) Whether the candidate is holding any office of profit under the Govemment of India or State Govemment ? No If Yes. details of the office held NA 3) Whether the candidate has been declared insolvent by any Court? No IfYes. has he been discharged from insolvency............... NA 4) Whether the candidate is under allegiance or adherence to any foreign country? NA.. 5) Whether the candidate has been disqualified under section 8A ofthe said Act by an order Of the President No lf Yes, the period for which disqualified NA 6) Whether the candidate was dismissed for comrption or for disloyalty while holding offlce under the Govemment of India or the Govemment of any State? No If Yes, the date of such dismissal NA (7) Whether the candidate has any subsisting contract (s) with the Government either in supply ofany good to that Government or for execution of works undertaken by that Govemment ? No If Yes. with which Government and details of subsisting contract (s) NA Y tu,yprvo l*^t- -5- (8) Whether the candidate is a managing agent, or marlager or Secretary of any companyi. Corporation (other than a cooperative society) in the capital of which the Central Govemment or State Government has not less than twenty -five percent share? ..... \g If yes, rvith which Govemment and the details thereof NA 9) Whether the candidate has been disqualified by the Commission under section l0A of the said Act No Ifyes, the date ofdisqualification NA 1 r,\A ( Yarlaga da Rama Mohana Rao) Place : Machilipatnam Signature of Candidate Date :25-03-2019 -6- PART-IV ( To be filled by the Returning Officer) Serial No . of nomination paper This nomination was delivered to me at my office at (hour) on (date) by the candidate/propose (name ofproposer Date Retuming Officer PART-V Decision of Returning Officer Accepting or Rejecting the Nomination papcr I have examined this nomination paper in accordance with section 36 of the Representation of the People Act, 195 I (43 of I 95 I ) of and decide as follows. Date Returning Of ficer Perforation PART - YI Receipt for Nomination Paper and Notice of Scrutiny (To be handled over to the process presenting the Nomination Paper ) Serial No. of nomination paper.......... The nomination paper of Shri Yarlagadda Rama Mohana Rao, a candidate for electiorr liorr the I I - Machilipatnam Parliamentary constituency was delivered to me at my office at (hour) on_ (date) by the candidate/ proposer. All nomination papers will be taken up for scrutiny at hour) on (date) at (place) Date : Returning Officer *Score out the word not applicable -7- I ,{- l= lffiq]sso Rs,. 10 \ oNE'"- a EI ht. f. :l 00 IiI I R E v EIoil Ef,-1 1 oo -I OU oo' oo -1 o<) 1 oo 1 oo oo I N I o 1 o c)r1 o o 1 oo -o(f o -t q t 1 1 o o -1 o rOO a 1 o c) 1 o roo ( -t o o 1 o :ootoo o o eeord d 5' e{r*r xfu 6Npt{RA pRADE'H 1 gffi6r tP gnr2 t ,3.e-rl? CH.VV.RAMANA RA r.