NIZAMABADIH5/199/2024

FORM 12(A)
See rule 20(2)
Application For Election Duty Certificate
To

The Returning Officer.,

4-Nizamabad Parliamentary Constituency.
Sir/Madam,

Tintend to cast my vote in person at the ensuing elections to the House of People from the 017-Nizamabad
(Urban) Assembly Constituency.

Ihave been posted on election duty within the constituency at (No. and Name of polling station)
but my name is entered at Serial No: 373 Part No 153 of the electoralrolls for 017-Nizamabad
(Urban) assembly constituency comprised within 4-Nizamabad Parliamentary constituency. My Electoral
Photo ldentity Card No is IHL5047337

Ireguest that an Election Duty Certificate in Form 12B may be issued to enable me to vote at the polling station where
Imay be on duty on the polling day. It may be sent to me at the following address:

Contact No: 9505765339

Yours Faithfully,
Place
Date: (Signature of Applicant)
Name: G BHAVANI(EID: 44318), SENIOR ASSISTANT
ZPHS JANKAMPET ,YEDAPALLY MANDAL, ZPHS
JANKAMPET,YEDAPALLY MANDAL, SCHOOL
EDUCATION DEPARTMENT, YEDA PALLE (MANDAL),
NIZAMABAD (DIST)