PROFORMA al Residential/Domicile Certificate for candidates residing in the State of West Bengal ‘continuously for at least last tan (10) years as.on 31.12.2019 Ceitied that Array Mandef Son / dgughfer of 26) a Mandal Is a resident/permanent resident of West Bengal at Viligge/House No. Aischi'ndspure Heute se-184 Street post office Ph adas police Station hata In the District of Posehimn Mebiiatfyysnder 234 Ghabal £20) — ‘Assembly Constituency and has been living in the State of West Bengal continueusly./ uninterruptediy at least for the last ten (10) years as on 31-12-2019. [Aastra Canuidate must sign here in front ofthe certifying authostty eae. mn photograph) Signature of Certifying Authority Ghee hinory Designation with Ofc! seat_CLOUNEZE > Councillor aval Muaicapality Fall Name of Certifying Authority Gira ADnkary tebe" Office Address . ™ wat] Office Phone No. Mobile No: 9674 Lia/ 3 OF (optional) ID No: {optional) Note: Phatograph isto be attested by the certifying authority. The Certifying Authority should preserve a duplicate copy af this Certificate.