Form B

RASHTRASANT TUKADOJI MAHARAJ NAGPUR UNIVERSITY

An application for inclusion of name in the electoral roll, for election of Ten Registered Graduates to the Senate,
under Section 131(5) read with Section 28(2)(t) of the Maharashtra Public Universities Act, 2016.

To
	The Registrar, Rashtrasant Tukadoji Maharaj Nagpur University, Nagpur 440 033.

Sir,

1)	I request you that my name may kindly be enrolled in the electoral roll for election of Registered Graduates to the University Senate.
2)	My name is entered as a Registered Graduate in the year* Faculty of (Faculty Code No.) at Registration No. (Not more than 6 figures)* ..

3)	I hereby undertake that I have not incurred any one or more disqualifications as specified in Section 131(2) of Maharashtra Public Universities Act, 2016.

4)

Preferred Voting/Polling center (Refer list provided online for Code Nos.)

5)

I submit my particulars as under (As per List):
i) Full Name (Please write in Block Letters)

Surname/Last Name*

First Name*

Middle Name

ii) Address:

District*	Taluka*

Email ID	Mobile No.(10 digits)

4)	I hereby declare that I am not a Registered Graduate of any other University established by law in the State of Maharashtra. I hereby further declare that I am a Registered Graduate in the Faculty as I have selected above, of Rashtrasant Tukadoji Maharaj Nagpur University, Nagpur.

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