1. Name of Candidate : _______________________

2. Present Address
(i) Name of Jail : _______________________
(ii) Cell Number : _______________________

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

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

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

6. 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 Recogonised Government Psychiatrist)

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

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

9. 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

10. 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

11. What is your Annual Corruption Income? [ ]
A - 10-50 Crores
B - 50-100 Crores
C - Overflow...
(Convert all your $ earning from Hawala etc. to Rupees)

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

13. How many people have you killed or murdered ?[ ]
A - 50
B - 100
C - 1000
D - Lost count

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

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