Election to the Managing Committee members of.................................................... Co-operative Society Ltd.,..................................... Tahsil ........................................... District................................. for the............................................. Constituency.

To,
The Returning Officer/Presiding Officer
I............................................................................. ., candidate of present election do hereby request you that I have appointed Polling Agents at Polling Station No ............................................................... , Place as under for the poll to be held on ................................................ These Polling Agents shall also work and act as Counting Agents at the same of counting of votes on ..............................................................................
1. Shri., ......................................... Address............................................
2. Shri., ......................................... Address............................................

I agree to act as Polling/Counting Agent

Signature of the Polling/Counting Agent
Date:
N.B. The form duly filled and signed by the candidate shall be presented in duplicate.

Declaration of Polling/Counting Agent to be signed before the Returning Officer/Polling Officer

I hereby declare that I will not/at this election for .....................................
anything forbidden by the Act, or these Rules or by-laws thereunder