[Nomination Form under Rules 440, 448 and 452 (1)]

1. Name of the office for which election is sought..................................................................................................... 2. Full registered name of the co-operative society to which the office relates......................................................... 3. Candidate's - (i) Serial number in the voters' list............................................................................................................................. (ii) Full name *as i the voters' list)...................................................................................................................... (iii) Whether he is an individual member of the co-operative Society.................................................................. ...................................................................................................................................................................or (iv) Whether he is a representative of any affiliated society/body or authority....................................................... ...................................................................................................................................................................... If so, name of such affiliated society/body/authority...................................................................................... 4. (i) Fathers' name (in case of male candidate and unmarried female candidate) (ii) Husband's name (in case of married female candidate)............................................................................... 5. Proposer's - (i) Serial number in the voters' list...................................................................................................................... (ii) Full name (as in the voters' list)..................................................................................................................... (iii) Whether he is an individual member of the Co-operative Society.........................................................or (iv) Whether he is a representative of any affiliated society/body or authority................................................. ....................................................................................................................................................................... If so, name of such affiliated society/body/authority.............................................................................................. (v) Signature of thumb-impression...................................................................................................................... 6. Seconder's - (i) Serial number in he voters' list......................................................................................................................... (ii) Full name (as in the voters' list)....................................................................................................................... (iii) Whether he is an individual member of the co-operative Society..............................................................or (iv) Whether he is a representative of any affiliated society/body or authority.............................................. ................................................................................................................................................................................... If so, name of such affiliated society/body/authority.............................................................................................. (v) Signature of thumb-impression...................................................................................................................... Candidate's Declaration I hereby declare that I am willing to stand for election and that I am eligible according to the rules and bye-lows of the society to contest for the office to which I am a candidate. Signature or thumb-impression of candidate NOTE - (1) One or is to be used only for one candidate and for one office. (2) If the candidate/ proposer/seconder is illiterate, his thumb-impression should be attested by the officer of the society or by an officer of the Department. (3) Voters' list referred to in this form means voters' list as finalized after disposal of objection.