(See rule 4) NOMINATION PAPER Election to the House of the People............................................................. STRIKE OFF PART I OR PART II BELOW WHICHEVER IS NOT APPLICABLE PART I (To be used by candidate set up by recognised political party) I nominate as a candidate for election to the House of the People from the .............. ....................................................... Parliamentary constituency. 2[Candidate's name ........................................... father's/mother's/husband's name ........................................His postal address ..................................................... His names is entered at S. No. ....................... in Part No. ............................. of the electoral roll for ....................................................... *[Assembly constituency comprised within] ............................................... Parliamentary constituency. My name is ............................... and it is entered at S.No................................ ........................ in Part No. .....................of the electoral rolls for .................... *[Assembly constituency comprised within] ....................................................... Parliamentary constituency. Date .......................................................................... (Signature of proposer). PART II (To be used by candidate NOT set up by recognised political party) We hereby nominate as candidate for election to the House of the People from the............................................... Parliamentary Constituency. Candidate's name....................................................Father's/mother's/husband's name............................................................................................................. His postal address........................................................................................ His name is entered at S.No..................... in Part No..................................of the electoral roll for ..................................*(Assembly constituency We declare that we are electors of the above parliamentary constituency and our names are entered in the electoral roll for the Parliamentary Constituency as indicated below and we append our signatures below in token of subscribing to this nomination:_ Particulars of the proposers and their signatures. Sl. no. Electoral Roll No. of proposer Name of component Assembly Constituency Part No. of Electoral Roll S. No. in that Part Full name Signature Date 1. 2. 3. 4. 5. 6. 7. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. N.B.:_There should be ten electors of the constituency as proposers. PART III I, the candidate mentioned in Part I/Part II (Strike out which is not applicable) assent to this nomination and hereby declare._ (a) that I have completed...............................years of age; [STRIKE OUT b(i) or b(ii) BELOW WHICHEVER IS NOT APPLICABLE] (b) (i) that I am set up at this election by the.........................................................party, which is recognised National Party/State Party in this State and that the symbol reserved for the above party be allotted to me. OR (ii) that I am set up at this election by the...........................................party, which is a registered-unrecognised political party/that I am contesting this election as an independent candidate. (Strike out which is not applicable) and that the the symbols I have chosen, in order of preference, are:_ (i)........................................(ii)...........................................(iii).................................... (c) that my name and my father's/mother's/husband's name have been correctly spelt out above in.............................. (name of the language); (d) that to the best of my knowledge and belief, I am qualified and not also disqualified for being chosen to fill the seat in the House of the People. *I further declare that I am a member of the.......................................... **Caste/tribe which is a scheduled ***caste/tribe of the State of.................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 general election/the bye-elections being held simultaneously, to the House of the People from more than two Parliamentary Constituencies. *Score out the words "assembly constituency comprised within" in the case of Jammu and Kashmir, Andaman and Nicobar Islands, Chandigarh, Dadra and Nagar Haveli, Daman and Diu and Lakshadweep. *Score out this paragraph, if not applicable. **Score out the words not applicable. Date...........................................................................(Signature of Candidate) *Score out this paragraph,, if not applicable. @ Not applicable in the case of Jammu and Kashmir,Andaman and Nicobar Island, (Statutory Rules and Order) Chandigarh,Dadra and Nagar Haveli, Daman and Diu and Lakshadweep N.B._A "recognised political party" means a political party recognised by the Election Commission under the Election Symbols (Reservation and Allotment) Order, 1968 in the State concerned. 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), YES/N O 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.................. (ii) Police station (s) ......District(s) ......State(s) ........ (iii) Section(s) of the concerned Act(s) and brief description of the offence(s) for which he has been convicted ......................... (iv) Date(s) of conviction(s)........................ (v) Court(s) which convicted the candidate ................. (vi) Punishment(s) imposed [indicate period of imprisonment(s) and/or quantum of find(s)]................................. (vii) Date(s) of release from prison..................... (viii) Was/were any appeal(s)/revision(s) filed against above conviction(s).Yes/No (ix) Date and particulars of appeal(s)/application(s) for revision filed ...... (x) Name of the court(s) before which the appeal(s) /application (s) for revision filed ..................................... (xi) Whether the said appeal(s) / application (s) for revision has/have been disposed of or is/are pending ............................ (xii) If the said appeal(s)/application(s) for revision has/have been disposed of (a) Date(s) of disposal ........... (b) Nature of order(s) passed ....... Serial No. of nomination paper...................................................................... This nomination was delivered to me at my office at................................(hour) on....................................(date) by the *candidate/proposer. Date................................................ Returning Officer ................................................................................ (Statutory Rules and Order) PART V 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 ......................................................................Parliamentary constituency was delivered to me at my office at................................... (hour) on...................................................(date) at* 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.]
