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)