FORM 13

(See rule 25 (2) )
Appointment of Polling Agent


Election to the + ……………Grama ** / Taluk / Zilla Panchayat from the * …………Constituency.

 

I, …………………..a Candidate ** /  the Election Agent of ………………who is a Candidate at the above election do hereby appoint……………..Name and address…………….as a Polling Agent to attend.

 

Polling Station No. …………….at (Place) ………………fixed for poll at (time) ………………….

 

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


 
I Agree to act as Polling Agent

 

Place :  
Date :
  Signature of Polling Agent

Declaration of Polling Agent to be signed before the Presiding Officer

 

I hereby declare that at the above election. I will not do anything forbidden by Section 29@  of the Karnataka Panchayat Raj Act 1993 which I have read / has been read over to me.

  Signature of Polling Agent




  Signature before me




Date
Presiding Officer