1. Name of Candidate: ___________ ________ _

2. Present Address
(i) Name of Jail: __________ ________ _
(ii) Cell Number: __________ ________ _

3. Political Party: __________ ________ __ (List ONLY the Last Five parties in the Chronological (Order)

4. Sex: [ ]
A - Male
B - Female
C - Mayawati

5. Nationality: [ ]
A - Italian
B - Indian

6. Reasons for leaving last party (circle one or more)
A - Defected
B - Expelled
C - Bought out
D - None of above
E - All of above

7. Reasons for contesting elections (circle one or more)
A - To make money
B - To escape court trial
C - To grossly misuse power
D - To serve the public
E - I have no clue (if you choose “D, attach Certificate of Sanity from a Recognized Government Psychiatrist)

8. How many years of public service experience do you possess?
A - 1-2 yrs
B - 2-6yrs
C - 6-15yrs
D - 15+yrs

9. Give details of any criminal cases pending against you (Use as many Additional Sheets as you want)

10. How many years have you spent in Jail? [ ] (Do not confuse with question 8)
A - 1-2 years
B - 2-6 years
C - 6-15 years
D - 15+years

11. Are you involved in any financial scams? [ ]
A - Why not
B - Of Course
C - Definitely
D - I deny it all
E - I see a foreign hand.

12. What is your Annual Corruption Income? [ ]
A - 100-500 Crores
B - 500-1000 Crores
C - Overflow... (Convert all your $ earning from Hawala etc to Rupees)

13. Do you have any developmental plans for India in mind? [ ]
A - No
B - No
C - No
D - No

14. Describe your achievements in space provided: [_________]
15. Thumb Impression of candidate (Not that of the person who filled the form)