Name (Full Name):*
Relative Name:*
Mobile No:*
Whether the advertisement is by a *
(name of advertiser):*
In case of political party, the status of the party:
In case of a candidate, name of the Parliamentary / Assembly Constituency from where constesting:
Address of Headquarters of political party / group or body of persons / association / organization / Trust:
Is the advertisement for the benefit of prospects of election of any candidate(s):*
If so, give the name(s) of such candidate(s) with full address and name(s) of constituency(ies):

To be certified on or before:
Language(s) used in the advertisement : *        
Media where the advertisement is to be telecast: *
Name of Media on which the advertisement is proposed to be telecast:*
Title of advertisement: *

Cost of production of the advertisement: *  
Number of Insertions/Days to be telecast/advertised: *
Rate of telecast/advertised per Insertions/Days: *
Approximate cost of proposed telecast :
Total expenditure involved (in Rupess)
I, Shri / Smt    S/O / D/O / W/O   

(full address)    undertake that all Payments

related to the production and telecast of this advertisement will be made by way of cheque / demand draft.
PART III (Applicable for advertisement by a person / persons, other than a political party or a candidate)
I, Shri / Smt    S/O / D/O / W/O  

(full address)   hereby state and affirm that

the advertisement(s) submitted herewith is not for the benefit of any political party or any candidate and this

advertisement(s) has / have not been sponsored / commissioned or paid for by any political party or a candidate.
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