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FORM-19(TEACHERS)

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

Applicant Photo: 

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:

1. Applicant's Details:

*Name:
Surname (if any):
*పేరు:
ఇంటి పేరు:
*Relation Name:
Relation Surname(if any):
పేరు:
ఇంటి పేరు:
Date of birth:     Day:    Month:  Year:  Age:
Gender: Relation Type:

House Address(Place of ordinary residence):

*House/Door number:
*Town/ Village:   *Tehsil/ Taluka/ Mandal/ Thana:
*Street /Area /Locality /Mohalla /Road:
*Town/ Village:
*Post Office:
*Pin Code:

Details of AC & EPIC, If the applicant's name is included:

District:
Ac No & Name:
EPIC No(ID CARD NO): Polling Station No:
Sl.No in PS:
2.During the last six years I have been engaged in teaching for the total period of more than three       
   1.Name of Educational Institution      from  to (DD-MM-YYYY)
       
    2.Name of Educational Institution     from  to (DD-MM-YYYY)
   
    3.Name of Educational Institution     from  to (DD-MM-YYYY)

3. Date of Entry into service (DD-MM-YYYY) as a Teacher

       Date of Retirement (DD-MM-YYYY)   

4. In support of my claim as being a Teacher in profession,I submit herewith as being a Teacher in profession,I submit herewith
5.My name has not been included in the electoral roll for this or any other Teacher's 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.
House No:
Mohalla:
Town/Village:
Mobile No:
Email ID:  
I declare that I am citizen of India and that all the particulars given above are true to the best of my knowledge.