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. Edited!!

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: [_________] 
Thumb Impression of candidate (Not that of the person who filled the form)