Form-19

Note: All Star(*) Fields are Mandatory...Upload only JPEG images and Image size should be below 100KB...Use Firefox,Chrome and IE-11 for best view

FORM-19(TEACHERS)

Claim for inclusion of name in the electoral roll for a Teachers' Constituency

To,

The Electoral Registration Officer

Teacher's Constituency *

District *

Sir, I request that my name be included in the electoral roll for the above Teacher's Constituency. Particulars in support of my claim for inclusion in the electoral roll are given below:

Applicant's Details

Name*

పేరు*

Surname (if any)

ఇంటి పేరు

Name of Relative of Applicant*

బంధువు పేరు*

Surname of Relative

బంధువు ఇంటి పేరు

Gender *

Type of Relation*

Date of Birth*

Address Details(Place of ordinary residence):

House / Door Number*

Street /Area /Road *

వీధి / ప్రాంతం *

Town / Village *

పట్టణం / గ్రామం *

Tehsil/ Taluka/ Mandal*

తహసీల్/ తాలూకా/ మండలం *

Post Office *

తపాలా కార్యాలయము*

Pincode*

Disability (if any):- (Tick appropriate box) (optional Filed)

Visual impairment

Speech & hearing disability

Locomotor disability

Other Disability

Whether registered as an elector for any assembly constituency, if yes, then mention the following

District

Ac No & Name:

Epic No(ID Card No)

Polling Station No:

Sl.No in PS:

Aadhaar Details:- (Pleas tick appropriate option):

Aadhaar Number

Iam not able to furnish my Aadhaar Number because I don't have Aadhaar Number

During the last six years I have been engaged in teaching for a total period of more than three years

From

Upload Supporting Documents

Your Photograph*(Image size should be below 100KB)

Your Certificate (Image Format Only)*(Image size should be below 200KB)

My name has not been included in the electoral roll for this or any other teachers' constituency

(OR)

My name has been included in the electoral roll for Constituency

and District

under the given address below and I request that it to be deleted from that roll.

Mobile No:

Email ID:

I declare that I am a citizen of India and that all the particulars given above are true to the best of my knowledge and belief.

Place:*

Date:

Note: Any person who makes a statement or declaration which is false and which he either knows or believes to be false or does not believe to be true is punishable under section 31 of the Represention of the People Act, 1950.

Note: All Star(*) Fields are Mandatory...Upload only JPEG images and Image size should be below 100KB...Use Firefox,Chrome and IE-11 for best view FORM-19(TEACHERS)