FORM 4

(See rule 14(1))

Nomination Paper

 

Election to the Taluk Panchayat / Zilla Panchayat
 

I, nominate Sri / Smt………………….as a candidate for election to the *………………Taluk Panchayat**/ Zilla Panchayat / ……………..district from the * …………………constituency / constituency reserved for Scheduled Castes ** / Scheduled Tribes / Backward classes / Women. 


Candidate’s Name :  
His / Her father’s / husband’s Name :  
Postal Address :  

           
His / Her name is entered at Sl. No. ……………..in part No. …………….of the electrol Roll for the constituency.

 My name is ………………..and it is entered at Sl. No. ……………..in part No. …………of the elector roll for ……………….Constituency.

Date :
                                                                                                                                                       Signature of the proposer

 

* Appropriate particulars of the election to be inserted here.
** Strike off the inappropriate alternative.

(to be filled by the Candidate)


I the above mentioned candidate assent to the nomination and hereby declare:- 

(a) That I have completed………………years of age.
 
+ (b) That I am a Woman.
+ (c) That I am a member of…………….Caste / Tribe / class which is a schedule caste / schedule tribe / Backward class of the State of Karnataka. A copy of the Schedule Caste / Schedule Tribe / Backward Class certificate issued in my favour by the competent authority is enclosed.
+ (d) That I am set up at this election by …………….Party.
(e) That the symbols I have chosen in the order of preference are:-

I
II
III
     



Date :
Signature of Candidate

+ Score out the clause not applicable.

                                   

(to be filled by Returning Officer)

                                                                                                                                                                  

Serial number of Nomination paper :

 This nomination was delivered to me at my office at……………..(hour) on ……………...(date) by the candidate * / proposer……………(Name)

 

Date :
                                                                                                                                                       Returning Officer

+Score out the clause not applicable.

  

 

Decision of the Returning Officer

Accepting or rejecting the Nomination paper. 

           
I have examined this nomination paper in accordance with rule 17..of the Karnataka Panchayat Raj (Conduct of Elections) Rules 1993 and decide as follows.


Date:
Returning Officer

                                    

                                                                                                                                                                  

Receipt of nomination paper and notice of scrutiny

(To be handed over to the person presenting the nomination paper)

 
Serial number of Nomination paper :

 The nomination paper of ……………..a candidate for election to the * ………….Taluk Panchayat / Zilla Panchayat from the * …………..constituency was delivered to me at my office at ……………(Hour)……….(date) by the candidate ** / proposer.

 All the nomination papers will be taken up for scrutiny at ………………..(Hour) on ………….(date) at………………(place).


Date:
Returning Officer


* Appropriate particulars of the election to be inserted here.