APPLICATION FOR OBTAINING DISABILITY CARD

1.         NAME …………………… ……………………………… ……………………..

                        (Surname)                                (First name)                              (Middle name)

2.         FATHER’S/HUSBAND’S NAME…………………………………………………

3.         DATE OF BIRTH…………………………………………………………………..

                                                (Day)                           (Month)                                    (Year)

4.         SEX………………………………………………………………………………....

5.         CASTE……………………………………………………………………………...

                                    (Please state if you belong to SC, ST or OBC categories)

6.         ADDRESS:  State here permanent address and address for communication.

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

7.         EDUCATIONAL STATUS:

            (please indicate School and Collage degrees obtained)

8. FAMILY INCOME: Rs.……………………………………………………………….

(Note: Addd income of all the earning member og the family living together in the same     household)

9. OCCUPATION: …………………………………………………………………………

(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:

            10.23   Name and address of employment exchange:

11 IDENTIFICATION MARKS:

            (1)       ………………………………………………………….

            (2)       ……………………………………………………….....

12. NATURE OF DISABILITY…………………………………………………….

(In case of locomotor disability, indicate percentage of disability, in the case of Mental Retardation, mention here severity of disability, if indicated in the medical certificate given, here the Specific Diagnostic category indicating the degree of disability such as International Classification of Diseases code number.)   

14 . PARTICULARS OF MEDICAL CERTIFICATE

            (a)        Medical Authority issuing the certificate.

            (b)        Date of issue.

            (c)        Whether disability condition is permanent or correctable.

15. SIGNATURE AND THUMB IMPRESSION OF PERSONS WITH DISABILITY.

(1)…………………………………..              (2) ………………………………………..

(3)…………………………………..              (4) ………………………………………..

      (Right hand thumb impression)                               (Right hand thumb impression)                        

SIGNATURE AND STAMP OF AUTHORITY ISSUING THE DISABILITY CARE.

DATE:                                                             SIGNATURE OF ISSUING AUTHORITY

PLACE:                                                           STAMP

NOTE:1) This application form can be used for obtaining disability card in case the
            original disability card gas been lost and duplicate card is required to be obtained
            for format of application will remain the same.

            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 affixing on the disability card.