GOVERNMENT OF
OFFICE OF THE WELFARE
OFFICER ( N/S/E/W )
SOCIAL JUSTICE, EMPOWERMENT AND WELFARE DEPARTMENT
APPLICATION FORM FOR OBTAINING DISABILITY
CARD
Recent Photograph
1. Name :- ------------------------- ----------------------- -----------------------
( Surname ) ( First Name ) ( Last name )
2. Fathers/Husbands Name :- ---------------------------------------------------------
3. Date of Birth :- ----------- ----------- ------------
(dd) (mm) (year )
4. Sex :- -------------------
5. Caste :- ----------------------------------------------
(Please state that if you belong to SC/ST/OBC categories )
6. Permanent Address :- -----------------------------------------------
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7. Educational Status :-
( Please indicate school and college degrees obtained )
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Educational Qualification |
Year of passing |
Name of School / college |
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8. Family Income :- ------------------------------------------
( Note :- Add income of all the earnings members of the family living together in the same house hold )
9. Occupation :- -----------------------------------------
( Note :- Describe here official designation and also nature of work performed by you )
10. REGISTRATION IN EMPLOYMENT EXCHANGE :-
10.1. Registration Number :-
10.2 Date of Registration :-
10.3 Name and Address of employment exchange :-
11. IDENTIFICATION MARKS :-
(1)
(2)
12. NATURE OF DISABILITY ---------------------------------
( Indicate here the category of disability or diagnostic description of the disability as given in the Medical Certificate issued by the designated Medical Board. )
13. DEGREE OF DISABILITY ---------------------------------------
( in case of locomotive disability, indicate percentage of disability in the case of Mental retardation, mention here severity of disability, if indicated in the Medical Certificate give, give here the specific diagnostic category indicating the degree of disability such as International Classification of Diseases code number ).
14. PARTICULARS OF MEDICAL CERTICATE :-
(a) Medical authority issuing the certificate
(b) Date of issue
(c) Whether disability condition is permanent or correctable
15. SIGANTURE AND THUMB IMPRESSION OF PERSONS WITH DISBAILITY
(1) ----------------------------- (2) -----------------------------------
(3) ----------------------------- ( 4 ) ----------------------------------
( Right hand thumb impression ) ( Right hand thumb impression )
16. SIGNATURE AND STAMP OF AUTHORITY ISSUING THE DISBAILITY CARD
DATE : --------------------
Place :- --------------------------- Signature of issue authority
Stamp
NOTE (1) This application form can be used for obtaining disability card in case the original disability card has been lost and duplicate disability card is required to be obtained for format of application will remain the same.
NOTE (2) Please attach four ( 4) passport size photographs. One photograph be affixed on the application while the other photograph be stapled along with the application form, the second photograph will be used for affixed on the disability card.
NOTE ( 3 ) Please attach a copy of the Medical Certificate obtained by you from the authorized Medical Board constituted by the State Government.
NOTE ( 4) Please attach Sikkim Subject / Identification Certificate