WBIEE-2019 Information Bulletin Page: 33/71 APPENDIX -1 PROFORMA a1 Residential/Domicile Certificate for candidates residing inthe State of West Bengal continuously for at least last ten (10) years as on 31.12.2018 certified that__Cnivan OANDEY Son / daughter of RAMANMUT PANDEY is a resident/permanent resident of West Bengal at Village/House No.__51 [1 / A113 street RABPNORA SAR AN Post Office_1 7 LU AH Police Station IT LUAH In the District of _ HH OUOR AH under Assembly Constituency and has been living in the State of West Bengal continuously / uninterruptedly at least for the last ten (10) years as on 31-12-2018. Sliven Pandey» Candidate must sign here in front of the certifying ‘authority Salkia, Howr Signature of Certifying Authority S:K-Chewbrey Designation with OfficialSeal__ T.TC. Full Name of Certifying Authority S41 rosy k mar cl HL ug oe office Address 3 FJ / 8. D-Jane Selle , Hows- (+ office Phone No. Mobile No: 421490039 (optional) 1D No: (optional Note: Photograph is to be attested by the certifying authority. The Certifying Authority should preserve a duplicate copy of this Certificate.