vt"tl2 ( FORM 2B (sccrole4) NOMINATION IAPER the Legis lativ. Ass e,iblr' ol. 4] 5r|4.,....(.tare) I STRIKE OFF PART I OR PART II BELOW WHICHEVER IS NOT APPLICABLE PART ! (To be used by candidate set up by rccos sed politic.l partv) I nonimt€ $ a candidate for elcction lo fie Lesislative Assmblv fton lhe.7.A.L(A .r$aAu!...Assenbly Con{ilucncv. CrndidarCs nane... .ld$Tr.sl.tl d4{..Ji.Lrr:4...... .. Fatbeivmodels/husbdds nanetaiE.r..ls:!€i.nnclautdllis posbl ad.lrcss ea:t4r-"pril<AiJ_r'Al\ANr.r' . His .anc is enlered at sl :Darf. ".RA!Ad.qrA..."Dr*la .'.26.7t.34... No..(AL....inPaftNo....53:....oftheelecroralrollfor74--l.ANr'ABAtllir...Assmblv My nme is ..IUAA.035,JA$1........... and il is ot€rcd al Sl No .ll.61.. i! Pan No... 55:....,of lhe clccloFl rcll ftr ltE.7l.-l<AbrT Aala N-rl ...... Assnblv co.stitudcv Signature oflhe Popos YP,F we herby noninatc ss cmdida{e for election lo the Legisl.live AseDblv lion rh€......................................AssenblyConsduency candidate\ nanc...........)A......'''..- - --'''.-X Fathers/morheis'husbmd's .. ..-.{ ..HB poial.dd,es k ........1 ... 4 H\ name h enereJ ar sl No..-.f......inPadNo.....'^.....oflheclccloFlrollfor" . ....... ..Assenblv. I 0 : . We declare rhar wc are elecloB of thG /X Assembly conslitnency dd ou nmes {e chrered id for this Asscmbly constitucncy as indicoted below loten ot subscribins ro this noninalion: _ rrecor n,rrr,lo ot rro;i*i 2 l. 2. 3 5. 8. N B.- fherc ",oLtd d" rn d.. ua;;;;;;;;;;;;;;; _n,"n . no, .po ," ",.rr;i_li'J,.''. ",, cdb,e, a{en, ,o " "";ll;;i,f:*'T;l'Ti r,l Ie,^dih of.rd'1nd tu\e ro! d.qu,,ed rhe \rri/m.hrp o, ey ro, an Sr,re. r0r rhar thave comptr'ed... ... )edsofaEe, ISTtuKE OUT c(i) OR c(ii) BELOW WHTCHEVERIS NOT APpLICABLEI n) /il - .T up Jr (teclon er l1.. b\ rhe.. ... .. ..pny. w1,ch rs recognFed Nd P"r) \J]rl,a-, n.. qne ^.al - ald rha he sya6o. rcsens to, Lhc pany be allored lo me "bo\e OR p'(crion rhe - by __ .... ...... .pry. qhi.1 F d Rgrnneo_] 11 l:' rtwogn{d".hi. poLrtat l"n D"1J .har I d contesrng -hi. ete.nol s ,l .ldeoc.d.nt.andidaro rSr L" our qt-trh gc n nor appt.!able,,nd |ndr rflbot. I hrve choser, ordcrufprcrerencc. rre._ 'n ror ."lik; ;; (N6lrrlid;";;;,ll;',;;,'#" ;,#'l;""T;;.* :;;,;;;; -bo.c 4 .. rlnco,rhe.d,dxaBrJ ma "' dbql' ned ifi:lj:'.ij'Ji iti:".5"1:;ilj$!ti:l it^,ll.lti Tf;l,j,so ' I fLr F, !e. i . .tTr Jmd heribp.of.fe ... !... .rcalkhbewhrhhdnhedltcd "cereribco.Lhcs'ieo ....> ... ",".,r,;b. .2/ .... ,dea,mrt,,.skk ( lso declde thal l have nor been. &d shall not be noninatd * a cddidale at the p$ent go@l electiodlh€ by€-€l€clioB bcing held simultanously, to the trgislative Assedbly ODl.lltr of(State) nom noe dan lqo Assenbly conslitucncEs. 6'^t 4 s*4 Ja't'uf a Dak..4'(. 3.i:rsq Srgtum ofrddidale f PARTIIIA Go be filled by rhe cand'ddO (l ) wlEthd ihe candidalr (i) b$ bed conlhled $dion( o' G)oidyor.n\(tuido "ub ) (b) for conrrsvention or any law sp4ified in sub sction (2) ofseclion 8 oflhe Represertation ofthe People Act,l95l {43 of l95l)i or (ii) ha b*n conviced for a.y oth( offcncc(t for which be h6 been renrnced o impr .onmPnr 'b' a o ) cds or morc. Iflhe mswer is "Yel,lhe candidare shlll funnh the followinginfomrlon: (ilC!'efir{ infomdtion repod Nu Nos .< (ii) Police slarionG). ...x..... ....Dhtric(t....:.$.... ......stat€G). .. .. (iii) sationG) of rhe concemed Ac(t and bnef descnpdoo of the ofience(9 for which he bs been convicleq . .. ....... 4. - DareG) of corvicrionG).. ........X...... (v) Counc)shich convnkd lhc.rdidJre . (!i) Punilne.lG) imposed [indicate pe od of imprisonnentG) d<Voi qlMld of i\ri) Da,c,J ofrcrca.c rrom prhd x (viii) watw€E any appcal(s)tevision(s) filed against above convictionG)... .. .. ..YsNo (ix) Dare a.d panicula^ ofrnc appcalG)hpplicationG) for revision filed .... .. .:. ..... .. .. 'x (x) Namo of rbc conrrG) befoE wbich rhe appeal(s)/applicaiionG) ror ievision rtcd. .......l ....... (xi) *rhelh6 the eid rrpdalG)/rpplication(s) for rcvision has/havc ben disposed of or n/fe p..ding........... ...X........ (xii) If the eid appealG)/applicario.G) for rcvision hathavc been dhposed or- (b) Nat@ ofoide(t pascd.... (2) wllether d. cmdidrre is holding sny offrce ofprolit udcr thc Govmnc of India or shre Govmenr? . .... (Y*No) .ll\e..debihofrhcofl.cel'eld --. --.^--. .. (3) Whclhe! the cadidate hd b,rn deltred insolvent by an] Coun?. ......... (Y64'ro) 'lfY!\, hashcbendi{h,'seJ lion iNolvln\y ,x (4) whdher the cmdid.re n undq arlesimce or adhecnce ro my forci8, counrr/ 2X.. (\+:No) Jr\ei gtredebil....... ...... ..) (5) Whethd rhc cmdid{e hqs ben disqualilicd undq $ciion 8A of the sid Act by an oidd of rhc PHidenr?.'^ .. (\+!No) lfYcs,thcleriodlorwhichdisqualincd............., . (6) whether rhe cmdldat was dhmissed for .onprid ot for dd.yalry Nhile holdin8 ofica u fl fie Govemmcnr oflndi! or rhe Govenmol ofmy Sra!!'?...ix. (YaNo) JlYcs. lhe&r. olsnchdishi$.1. ....X........ (7)wherher thccandidarchas my subsisrins .onhdG) wrh thcCovemne eithcri.individual capacity or by tnsl or Dadnc6hip in which fie cDdidrte hrs a sharc lor sut'ply ormy goods orh .o\cmncro' -e\+-'i 1or n\' h"'Lo."mm-dr2t k "o'krLndcrs ^d lf Ycs, withvhich Covcmncnr and derrils of subsisringcmte(t.. .,< ... (3) whdher the cmdidare is a mnaging agcnr. or nmaE.r or Seicrary olaty compuy or Corpoialon (olhs than a coopcnrive so.icry) in dF capiial of shich the CdhV Govcnn'cd or sbre Govemcnr h6 not les thm twenty fiw p*e shrc?.. .x . (v.sbo lf Yes. wnh which Govchhcnr and thc dctlik rh{eot.... A (9) wllcrhci thc caDd idare has been disqua lificd by rhc CoDmhsion nndcr se rion | 0A of lhc eid -If yes,thedrteofdisqualifi ton. y €g,ttffi'f"^u{' 24.7- t1 (ro be trbn by $c Rddn'ir8 omet Serial No. of non jnltion papcr.... eN{.|.c - ,,?^ This nominadon was d€l dscdtdme d my oma d \+?>(r'dw) * rhe ca.didalc/poposer (N ane ). D.E. d4d\\ €lqa et g6qt og lc|ae q€d|eo lefio ra* (c)/e9q(Q)l s, ........s-5.6!9....e€r....er4fi.J...._,...,,,,,.._....,,,,,,_...., elelqel a 'i 6n|cQEI sadr66Gl..- .oc ane qoo qcerfie ecqeos€ m'o ffiffiffi cge 60 iiasnA{ q6€e cnee a'fti|eo6o aqo g .{e qt*{tqq 8{E u Et oqe cnee e !eo€r9 qq{iP e66 | S.4..n2 s*n (gralco q|6o 0 -| qr9,e aee€o en) j, or?r lQo6otar oE c ma! | aar roa) o.... ..NLF.:.. ..... o€e....,.......p1............ er66o .. ...'?1..:..?*.....f ll. o|6estsnar.'s,rsra....F.€:.an"gc1....1. eqo, Tl:.lllafl "n-- :.... mlqqs6a a{ec en6e doa ?ar6ot/q6{6$ et€6o q6a ea|o^,, ,! -&1-'1 e'$:iffs#tT#"o) lt&m6 Fo 4s.€mbly Co8rfiu.ncy ofioreiQvn oorsHe Or' t AIFIDA\'IT TO BE IILED BY TTIE CANDTDATE AI,oNCWT I NOMINATION PAPER EEFORE TIIE RETURNINC OTFICER FOR ELECTTON 10 ODISHA LECISLATI!'E ASSEMBLE IROM -7G KANTAIANJI ql tr CONSTITTJENC Y. kirl !4BTA !'son/of g- l, SANTOSE S|]\GE SALUJA, LATE INDER SING SEALUJA, Agc j9 y@ rAidenl of aT- KANTATTANT, p.o/p.s.,l({NTABANJT! DISTRTqI- ronncn, ooriaA t, PIN- 7670J9. a ,r he abole tr I "rndrd.'e etdrio-. do nerb) stennty amm ond 5bk on oa r 6 ? (l) I d a qndidde sl up by INDIAN NATIONAI CONCRESS t My name is enrclled i2) in 70- KANIABANI OF ODISqA STATE or Seial No.992 I in Pat No.55 OI (ANTABANJI contofl qt-94j7063316 .d I lJ). .M) tclepl-one ndmben{, i! dd mJ emait n s{dluja60@smait,com dd frl :ociat n eora aMrnL k (i) whahaap No. t43?068846 €-€*, ta s-n <d^'1 ? -L .Ktffiffi 4dtt'21t3-7ot\ Kft)e-r+tuq/>7/ 6:, u)'- 4' Ll-4 ^ Og'n- ' { @;6-o 1^,^E s4> <.!ls_)4r-2.," ,HiNr(APLa(fixF I !TAMPvENDTq (. (4) D.tails of Pe.nirent Accoutrt NuDbcr (?Al9 Md stltus offiling orlncomeid rclurn: Sl,Nu. rhoM i. Incone Td Retum (in Rup*t for :he l6t five Fimncial Yds conplet€d (sonll'l SANTOSH SINGH r017-2018 (i) z01l-r4 - Rs.4,68,r 00/- SALUJA (SELF) iD 2014-15 RS,4,98,536/. iiD tol5-t6 - Rs,6,7o,281/- (iv) 2016-r? - Rs,8,4s,749/- (v) 201?-r8-Rs.6,81;9r/- 2. RABINDAR XAUR I01?-2014 (i) 2013-14 -RS.3,01,654t iD 2014-15-RS.r,59,707t iiD 2015-r6 - RS.1,55,766l- t016-t1 - R5,2,91$12t- 201?-t8-RS.3;7,122l- 3. \OT NOT (D NOT AIILICAI}LE A}PLICABLE APPLICABL (iD \OT APILICABLD E iiD \OT APPLICABLE \OT ATTLICABLE NOT '\PPLICADLE NOT AP?LICABLE (iD NOT APPLICABLE iiD NOT APPLICADLE tiv) NOT APPLICABLE t4 NOT APPLIC,\BLD 7r;} ;) :'M9 1-",,t S q,t'lo , -,.i,1 a_ 3,j,tq M 8tqLfufr W)'l*o NO)T PUFllc' iAlf \B AN r-767039 foUoYitrg crininrl ca36 rrd (CASE NO. D Table (a) FIR No. with nde ed addre$ of Rl.RNo- 166 of201l, K!trrabanji P.s, AVI.OJP,S.- K!trrabarji , DbrBrhngir Odish, Casc No. with nme of the coun C.R. ClseNo-362 of20U G) S€clios of concened ActVCod6 S ecriia-r 47,4s2 263 22s ;07, involved Give no.