FORM-28 r(iJ '\"'\ (See Rule 4) ~ ,'O'o NOMINATION PAPER ELECTION TO THE LEGISLATIVE ASSEMBLY OF J.Y.~..V..~ .~ . f. ~ . ~~.. STATE (Strike off Part I or Part II below whichever is not applicable) Re ize 1 (2c m) phi in wh 1ite bac full fa c PART-I (To be used by candidate set up by recognised Political Party) •.ri nominate as a candidate for election to the Legislative Assembly from the 17 .~ .. N . 9: . ~ . r .T~. ~f.!jssembly Constituency. Candidate's Name............N.A.r..: .A..'i. hr:!. ~S. 17..~..4..... .... ..... ............ Father's I ~s I Httsb~ Name .. .. ...... Y.. ~ .. ~ .. V. .... ............ ............... His postal address .... N.<?... ?.~ ... .f.i. b.!-::: . AJ/t.~ . M . fr . ~ ... ..~9..1 L- .J1}'12..e C:::-(T ........................... .. .....£ . ~~. ~ ..kl:r.£~4... : .fl...~ . r.~ "tJj_ . His name is entered at S.No.i11. in Part No .. ..i..... of the electoral rol'I for .....4.~I ..<.--:. .RA.X.Y.S.H. .fl Y.IJ .r.!. ... .... .. ......Assembly Constituency. ~ y name is ..... V..§ .. ~'l\. V./J . t-!.. ~....................... .. ...... and it is entered at S . No.~3 in Part No .. B.~ of the electoral rolls for .!1.:-:-.. t!.<?...~. ~ . 1.H.P.£. ~ ...Assembly ~ Constituency. Date ... ./..n .:. JJ..~...~ .? . ~ ~ (Signatu e of proposer) ' \ 2 , -;t;T-11 (To be used by candidate NOT ~et up by recognised Political Party) We hereby nominate as candida e for election to the Legislative Assembly from the ...... .. ........ ... ..IY. o. '1./}fJ{ ~Afsfrn~ 1 ~~ stitue ncy. Candidate's Name.. .. .. .. ........ .. ...... .. .. N..9..T.. .. .!J.t.f...~ J ..~ . /)..~ ..Y. ~ Father's I Mother's I Husband's Name ..........N.6.f .. l?..P.P.. W. .. r:,,AIJ. .L 'E: His postal address ... ..... .... .... ... ... .... N.o.T. .. .. f.!. P..f.. '-::-:-. ~ ...C . f.t.lJ. t.... ~ His name is entered at S.No.. ... ... .. in Part No .... .. .. ... of the electoral ron for ....... .. ... .N~flJl..£ ..k .. l ..C. ./J..IJ... ~..f'Assembl Constituency. We declare that we are electors of thi s Assembly Constituency and our names are entered in the electoral roll for this Assembly Constit uency as indicated below and we append our signatures below in token of subscribing to this nomir ation :- Particulars of the proposers and their si_c;inatures. I Electoral Roll No. ot proposer SI. Part No.of S.No. Full Nar e Signature Date No . Electoral in that Part Roll (1) (2) (3) (4) (5) (6) 1. 2. - 3. !IT JI P. L~ I c tt YI I t" . / 4. / - 5. 6. 7. 8. 9. 10. N.B:- There should be ten electors of the constituency as pro~ osers 3 PART-Ill I, the candidate mentioned ~ n Part l/ ~ art II (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) rJ \..- cotJG. R6S S' (c) (i) I am set up at this election by the "" . NV.! . ~~... ~~!~ .~ .... i arty, which is recognised National Party/State Party. in this State and that the symbol reserved for the above party be allotted to me. (ii) I am set up at this election by the ....... .... ...... ..... .. ...... .. .... .. party, which is a registered-unrecognised political party I that \am contesting this election as an independent candidate (strike out which is not applicable) a\ d that the symbols I have chosen, in order of preference are:- - ­ (i) ... ..r/Df ...I}.9. ~..~ . ~~ ~(~L~ ..... N(;/f..n2.J.lr. .\. ~):) .tft ii) .. No..T..1.t.,f.J.. .~.).. .<;.. ~ . 11 L t;' ' (d) my name and my father's/mother's/husband's name have been correctly spelt out above in ... f. ..~ . ~ - ~\$.H. (name of the language) (e) to the best of my knowledge and belief, I am qualified 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 m ber of the ................~..... .... .. **~ste/tribe which . ** . J1Lb 1s a scheduled caste/tribe of the State of........... ..........No1;)0ft.--1..... ... 1:: .... 1n re a ion to ........ .. .. ... .... (area) in that State. I also declare that I have not been, and shall not be nominated as a candidate at the present @eAerBI clcotion/the bye e ~ ections being held simulltaneously, to the Legislative Assembly of ...l~J)9. ..~H . ~ .@. y..(State) from more than two Assembly Consti~encies. v'611)_ ----- Date: .. .?.:f . :-: . 1.~ . :.Md b (Signature of Candidate) *Score out this paragraph, it 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 State 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) 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..............N.1.k ..... ......................... .. ... .. ... ' ' (ii) Police Station(s) ....NJ.k...... District(s).... N.J..k..... .... .... State(s) ......H..( .k.. .. .. (iii) Section(s) of the concerned Act(s) and brief description of the offence(s) for which he has been convicted ..... ..... .. .. ...... ... ...... .... ... ...... ..... ... .... .rJ.t..k ... ... .... ...... ....................... ... ..... ....................... ....... ... ... .... ... .. .... ....... .................. ......f\}.(..L-... .. ... .... .......... '''' ............ .'' ..... ...................... '' ''' '.. '''.' .... '.. '....... ''' '.'' ''' ''' '''.'''' '.. ..... ..·-,J .,·..l.-, .. ... .... ....................... (iv) Date(s) of conviction(s) ... ..................... N . ~...k .... .... ................... .... ........ ... ... .. ..... (v) Court(s) which convicted the candidate ......... f\).\.L.--........ .. ...... .. ....................... (vi) Punishment(s) imposed [indicate period of irnprisonment(s) and I or quantum of fine(s)] .................... ....... ..... ............................ N .\..l....,:;.. ..... ........ ... ....................... (vii) Date(s) of release from prison ..... ...... .... .r.J..'\ ..b ........ ..... ........ ........................... .. .. ' (viii) Was/Were any appeal(s)/revision(s) filed against above conviction(s) ...... ."*9/No. Nt L (ix) Date and particulars of the appeal(s)/application(s) for revision filed ..... N.r.'..v ..... (x) Name of the court(s) before which the appeal(s)/application(s) for revision filed ..... ... ... ....................................... ..........N.rk....... .. ... .... .. .................. .. ........ .. .... .... (xi) Whether the sa ~ d appeal'(s)/application(s) f~r revision has/have been disposed of or is/are pending ........... .... ......................... ···N·l- ·l-- ·· ··· ····· ........... ·· ····· ·· ····· ·· ·· ······ . (xii) If the said appeal(s)/application(s) for revision, has/have been disposed of - /'JI u (a) Date(s) of disposal ...................rY . ~ . ~ .. .. .. .... ... .. ..... (b) Nature of order(s) passed .............N\ .. k ... :-: ......... Place: ~ " '9 U c.. \;l- £tz-VZ..lf v -~ ~ Date: ~ J \\ ' '\_,-D\ b (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.. (hour) on . t::?~ .),..'.(l4:fdate) by the 'candidate/proposer ...... .':!:. .·... N.~~r?\mr.. (name). Date ...0..;i. /.11.{. t6 Rel urninJ;er * Score out the words not appl1icable RETURNiNG-OFFICER.vn·cum·· -~ DIRECTOR OF INDUSTRIES &COMMERCE PUDUCHEIUiV PARTV DECISION OF HETURNING 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-PY142611764663400 Certificate Issued Date 27-0ct-2016 05:01 PM Account Reference l'IYIPACC (SH)/ pyshimp17/ SARAM/ PY-PU Unique Doc. Reference SUBIN-PYPYSHIMP17218143673018840 Purchased by V NARA Y ANASAMY Description of Document Article 4 Affidavit Property Description NOMINATION FOR NELLITHOPE ASSEMBLY CONSTITUENCY Consideration Price (Rs.) 0 (Zero) First Party