FORM 19
[See rule 31]
Claim for inclusion of name in the electoral roll for a teachers' constituency

To
The Electoral Registration Officer,
.............................(Teachers') Constituency.
Sir,
I request that my name be registered in the electoral roll for the................…………………..(teachers') Constituency.
The particulars are:—
Name (in full)................. ………………………………………….Sex...………………………………………….......
Father's/Mother's/Husband's name (in full)……………………………………………………………………..............
House address (Place of ordinary residence):—
House No……………….........
Street / Mohalla...……………..
Town / Village.............……….
Post Office………….............
Police Station / Tehsil / Taluka / Mouza ………………………………………………………………………………….......
District …………………………………………………………………………………………………………….............
Age ……………………………………………………………………………………………………………...................
2. During the last six years I have been engaged in teaching for a total period of more than three years as follows:--
Name of Educational Institution From (Date) To (Date) Period
1.
2.
3.
4.
_____________________________________________________________________________________________
In support of the above I submit herewith.............................................................................……………………………….
……………………………………………………………………………………..............................................................…….
……………………………………………………………………………………..............................................................…….
……………………………………………………………………………………..............................................................…….
3. 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 the....................teachers' constituency under the address given below
and I request that it be deleted from that roll:—.
..............................................................
...............................................................
..............................................................
4. 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........................
................................
Signature of claimant.
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 Representation of the People Act, 1950.
Strike out the paragraph not applicable.
______________________________________________________________________
…………………………………………....... (Perforation)………………………………………..............
Intimation of action taken
The application in Form 19 of Shri/Shrimati/Kumari......………………………………………………………………….
address..................................................………………………………………………………………
……………………...........................................has been—
(a) accepted and the name of Shri/Shrimati/Kumari......................................…………… has been registered at Serial
No......................…………………………….. in Part No……………………………..…………
……........................
(b) rejected for the reason.............……………………………………………………………………….
…………………….
Date.............
Electoral Registration Officer
(Address)....................
.............................
.............................]
…………..…………………………………......................(Perforation)………………………………............................
Receipt for application
Received the application in Form 19 from Shri/Shrimati/ Kumari....…………….................................................
address..................................................……………………………………………………………
….…………………
Date.........................
Electoral Registration Officer
(Address)...........................
.........................]
To be filled in by the applicant.
____________________________________________________________________________