FORM-IV

[RULE-13]
Appointment of Polling Agent/ Counting Agent

Election to the office of President / Vice-President /Member from

..............................Constituency of the Committee of the.....................................
(Name of the Head Quarters)
in P.O................ in .................... Block in........................ District, Odisha,
Scheduled to be held on.........................
(Strike of whatever is not applicable)
To
The Election Officer
The Presiding Officer
......................... Polling Station
.................................................

I, .......................................... a candidate at The above election, do hereby give

(Name)
Notice that I have appointed .................................. appearing at Sl.No...............
of the final Electoral Roll of ......................... Constituency as a
(a) Polling Agent to attend................................... Polling -Station/ Booth
No.................... of Polling –station at...........................
(b) Counting Agent to attend the place fixed for counting of votes
(......................................)
Name of the place
(Strike of what is not applicable)

Place.......................
Date...................... Signature of the candidate

I do hereby accept the above appointment

Place....................... Signature of the Polling / Counting Agent

Date........................