Election to the Managing Committee members of ................................................ Cooperative Society Ltd........................................... Tahsil........................................ District...........................................from ..............................constituency.

To,
The Returning Officer /The Presiding Officer .......................................... I ...................................................................... , a candidate of the present election do hereby request you that I have appointed Shri .....................................as Polling Agent to attend Polling Station/Polling Booth No.................................. of Polling Station at

Declaration of the Polling/Counting Agent to be signed before the Returning/Polling Officer.
  I hereby declare that I will not at this election for....................................

constituency do anything forbidden by the Act, or these Rules or by-laws thereunder.