FORM 12

[See Rule 25(1) ]

Revocation of Appointment of Polling Agent


Election of Councillors to the City Municipal Council/Town Municipal Council/Town Panchayat of the City/Town of ……………………………… ….. from ………………………...*ward


To:
The Presiding Officer,
………………………..
………………………..


I, ……………………………………...……………………. a Candidate/Election Agent** of ………………. …………………… at the above election hereby revoke the appointment of ………………………………………………………….Polling Agent. ……………………………………….at the polling Station No…………………………... at ……………………………………(Place)


Place :
Date:
Signature of the Candidate
/Election Agent***

* Appropriate particulars of the election to be inserted.
** Score off the inappropriate altenative.