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Microsoft Word FORM-28 (See Rule 4) NOMINATION PAPER ELECTION TO THE LEGISLATIVE ASSEMBLY OF .J.?. VJ.?. ~ . ~U . f.~. ~~ STATE (Strike off Part I or Part II below whichever is not applicable) Re ize (2c m) phc in wh ite bac 'ull fac PART-I (To be used by candidate set up by recognised Political Party) I nominate as a candidate for election to the Legislative Assembly from the . 1. 7.~ . N.G..1:-:-:~ . ~..!..~ .~ft?Assembly Constituency. Candidate's Name........... .:>.J..A·g · ~ · .'/...It..~ . ~ . £fl . ~.9 .... ... .. ... ......... Father's I ~er's-1 Hlffibancfs Name..............V . ~ ..~ ..~............................. His postal address ...':-:1..~ ..?.."'::.... f.. ~ ..~. ft..f.. f!!:. ~.. '.!;, . !!. ~ ...... J.~ol L J'TfL<....'=EI ...... ... ........... .... g.Y. ..~..~.. ~~..l?~t3: . ~ . ~ .1?..9...SP o J . His name is entered at S.No ..~J~ . in Part No ...1-... of the electoral roll for ... ... .J4 .~ . P....Jt :J.. .13..l::f.I}..'I.ft..N. ........ ..Assembly Constituency. / My name is/ .. .J....1.. 1.'f. .~ . !r. N..hN..P../tM.................... and it is entered at S.No .J . i-~ . ~ n Part No...i£.. of the electoral! rolls for . i..7:-:-: . N . c. ~~.J71!P..RG. Assembly Constituency. Date...~..~ ..1.. 1. ~ .. ~ . ~ . ~ .t.. .. (S lgnature of proposer) 2 - , • P ,RT-Iii (To be used by candidate NOT et up by recognised Political Party) We hereby nominate- as candidat for election to the Legislative Assembly from the ....... ..t.'. ~ . f. ... l.Hl)lk .J..(f.f\\};e~y Constitue cy. Candidate's Name ... .. .......... ..rV.9.. C.b.J...f:..~. ) .. (ft.({. ~ . g_ .:...... .. Father's I Mother's I Husband's Narr e...... N. ~ . f.... ft..~!.. .~J.(; !?.. P..~ r.s:- His postal address ..... ... .N . ~ . T.. ... ft. !.. .~..~... <-. .ft. ..~. '::-:. .fi. .~........ His name is entered at S.No........... n Part No .. .. .. ..... of the electora 1I roll for .... .. .... .... No. ..T.. .... /t:f.. f... ~.. t~A'ss<f;bly c( nstituency. We declare that we are electors of this A',sembly Constituency and our names are entered in the electoral roll for this Assembly Constituenc / as indicated below and we append our signatures below in token of subscribing to this nomination - Particulars of the proposers and t eir signatures. Electoral Roll No. of proposer SI. Part No.of S.No. Full Name Signature Date No. Electoral in that Part Roll (1) (2) (3) (4) (5) (6) 1. 2. 3. (N 0 ( · fr) X f.....-1 L /TfJL G­ . 4. 5. I 6. 7. 8. 9. 10. N.8:- There should be ten electors of the constituency as proposers 3 PART-Ill I, the candidate mentioned in Part W!s:l U(strike out which is not applicable) assent to this nomination and hereby declare that:­ (a) I am a citizen of India and have not acquired the citizenship of any foreign State: (b) that I have completed .......6.q.... years of age. (Strike out c(i) or c(ii) below whichever is not applicable) "" ~ Tl {) (N'A- L- Co N(;,Jl.Gs s (c) (i) I am set up at this election by the ..b. NJ)..l..!V~................. party, which is recognised National Pa rt y/State-~y in this State and that the symbol reserved for the above party be allotted to me. (OR) (ii) I am set up at this election by the .............. ......... .. ............. party, which is a registered-unrecognised political party I that I am contesting this election as an independent candidate (strike out which is not applicable) nd that the symbols I have chosen, in order of preference are:­ (i) .... Nat..ll:Jtf.W4>:m$i) .. N.off.R. ~ - ~..Yt!1 . ~~ iii) .. ~t1..f../J . f. g~_ 1.. ~. P.:-. 0 LC­ (d) my name and my father's/m oUaor's/t:iu~ name have been correctly spelt out above in .....b.,.., .N. .\A"· ..u.s . .. .... w'. (Ti_ame of the language) (e) to the best of my knowledge and be 1lief, I am quallified and not also disqualified for being chosen to fill the seat in the Legislative Assembly of this State. *I further declare that I am a ember of thef/R'JtCrC..Jfll(L5!3}el.t rii be which is a scheduled **caste/tribe of the State of.. ... ......'Y.9..T......... .. .in relation to ................... (area) in that State. I also declare that I have not been , and shall not be nominated as a candidate at the present ~ e r e\!- 0 l e ~the bye elections being held simultaneousl,y, to the Legislative Assembly of .. 9..o.J).!!..<:J! .t?.~Y .. (State) from more than two Assembly CV·C ies~ Date: .. .. ~.. : .~a. .!. ~.\,,.6 (Signature of Candidate) *Score out this paragraph, if not applicable. **Score out the words not applicable . N.B.:- A "recognised political party" means a political party recognised by the Election Commission of India under the Election Symbols (Reservation and Allotment) Order, 1968 in the Stale concerned . 4 PART Ill A {To be filled by the candidate) Whether the candidate ­ (i) has been convicted ­ (a) of any offence(s) under sub-section (1 ); or (b) for contravention of any law specified in sub-section(2) NO ~/No of section 8 of the Representation of the People Act, 1951 (43 of 1951);or (ii) has been convicted for any other offence(s) for which he has been sentenced to imprisonment for two years or more. If the answer is "Yes", the candidate shall furnish the following information: ' (i) Case/First Information Report No./Nos ...............hl.t~ ..................................... ... ' " . (ii) Police Station(s).... N.t..L ..... District(s) ......... yV.~.L.-.......... State(s) ..... .f.J..1..L... (iii) Section(s) of the concerned Act(s) and brief description of the offence(s) for which he has been convicted ..............................................................f.V..i... .k.... ... ....................................................... (iv) Date(s) of conviction(s) ...... ..................N..\..k ........................................ .............. (v) Court(s) which convicted the candidate .. ....... N.!.. ~.................................... .. .... (vi) Punishment(s) imposed [indicate period of . i mpri~onment { s) and I or quantum of fine(s)] · ·· · ····· · ···································· ········· ················N ~ · .t..:...- ·························· ····· ' (vii) Date(s) of release from prison ..... ............... tJ.r...l-.:-................................. ............... /./ t L,. (viii) Was/Were any appeal(s)/revision(s) filed against above conviction(s) .......¥m/No. (ix) Date and particulars of the appeal(s)/application(s) for revision filed .... !:!. '. ~ .~ · ········ (x) Name of the court(s) before which the appeal(s)/application(s) for revision filed ............. .. .. ............. .........................................fV. 1.G ........ .... ... ...... ... ..... ........ ..... (xi) Whether the said appeal(s)/application(s) for revision has/have been disposed of or is/are pending ...................................................pJt'... .k ............................... I (xii) If the said appeal(s)/application(s) for revision has/have been disposed of - N r {___, . N1~ (a) Date(s) of disposal .................................... ... ......... (b) Nature of order(s) passed ......................................NtL--? . Place: £vS>u ~~fl-~~ V,.. Date: ,_.. \ \ · 1.---0 ib (Signature of the candidate) 5 PART IV (To be filled by the Returning Officer) Serial No. of Nomination paper ... ~ ...... This nomination was delivered to me at my office at .. 7:-:.' . ~ . 1:-:-.. ~ .).. (hour) on £?).} . ~!./. .. ~~... (date) by the *candidate/proposer .. ....\r•... N~T~·~f.. ... (name). Date .. 9.~ . J . ~ . ~JJ.O f '1 Retum~icer - ~ ti'etURNING-------- OFFICER. -cum· * Score out the words not applicable vn DlR~CtOR OF INDUSTRIES &COMMERCE PUOUCHERRY PARTV DECISION OF RETURNING OFFICER ACCEPTING OR REJECTING THE NOMINATION PAPER I have examined this nomination paper in accordance with section 36 of the Representation of the People Act, 1951 and decide as follows:- Date.............. .. .. .. Returning Officer ....... ......... ... ... .... ....... ... ... .... .... ..... ........... Perforation ........ ............. .... .. ... .. .. ... .... ............. ... ...... PART VI RECEIPT FOR NOMINATION PAPER AND NOTICE OF SCRUTINY (To be handed over to the person presenting the Nomination Paper) Serial No. of Nomination Paper .... ......... .. The nomination paper of ............... ..... ... .. ... .. .... ..... ............. ... a candidate for election from the ... .... .. .. .... ..... ... .......... ..... .. .. ... Assembly 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 words not applicable INDIA NON JUDICIAL e-Stamp Certificate No. IN-PY142612429562810 Certificate Issued Date 27-0ct-2016 05:05 PM Account Reference JMPACC (SH)/ pyshimp17/ SARAM/ PY-PU Unique Doc. Reference SUBIN-PYPYSHIMP17218145284010380 Purchased by V NA RAY ANASAMY Description of Document Article 4 Affidavit Property Description NOMINATION FOR NELLITHOPE ASSEMBLY CONSTITUENCY Consideration Price (Rs.) 0 (Zero) First Party V NARAY ANASAMY Second Party RETURNING OFFICER Stamp Duty Paid By V NARAYANASAMY Stamp Duty Amount(Rs.) 100 (One Hundred only) FORM-26 (See Rule 4A) Affidavit to be filled by the candidate along with nomination paper before the Returning Officer for Election to the Puducherry Legislative Assembly from the .J!l~ltti·~tpe Assembly Constituency ~OT4'9µ 0005160368 r PART-A
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