Name of Candidate: _______________________

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

Political Party: ___________________(List ONLY the Last Five parties in the Chronological (Order)

Sex: [ ]
A – Male
B – Female
C – Mayawati

Nationality: [ ]
A – Italian
B – Indian

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

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)

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

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

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

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.

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)

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

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

By: Jagadeesh, for www.19.5degs.com