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Amended Rules for PWD - APPLICATION FOR OBTAINING DISABILITY CERTIFICATE BY PERSONS WITH DISABILITIES PDF Print E-mail
Tuesday, 23 August 2011 15:56
Article Index
Amended Rules for PWD
Issue of disability certificate
Educational qualifications
Other terms and conditions of service of the Chief Commissioner
APPLICATION FOR OBTAINING DISABILITY CERTIFICATE BY PERSONS WITH DISABILITIES
Form-II
Form-IV
All Pages

"Form-I
APPLICATION FOR OBTAINING DISABILITY CERTIFICATE BY PERSONS WITH DISABILITIES
(See rule 3)

1. Name: (Surname) _____________ (First name) _____________ (Middle name) _____________

2. Father's name: _____________ Mother's name: _____________

3. Date of Birth: (date) _______ / (month)___________ / (year)_________

4. Age at the time of application: _______ years

5. Sex: _______ Male/Female

6. Address:

(a) Permanent address
__________________________
__________________________

(b) Current Address (i.e. for communication)
__________________________
__________________________

(c) Period since when residing at current address
__________________________

7. Educational Status (Pl. tick as applicable)

  1. Post Graduate
  2. Graduate
  3. Diploma
  4. Higher Secondary
  5. High School
  6. Middle
  7. Primary
  8. Illiterate

8. Occupation _______________________________________

9. Identification marks (i) __________ (ii) __________

10. Nature of disability: locomotor/hearing/visual/mental/others

11. Period since when disabled: From Birth/Since year ____________

12. (i) Did you ever apply for issue of a disability certificate in the past ______YES/NO

(ii) If yes, details:

  1. Authority to whom and district in which applied ___________________________________
  2. Result of application _________________________________

13. Have you ever been issued a disability certificate in the past? If yes, please enclose a true copy.

Declaration: I hereby declare that all particulars stated above are true to the best of my knowledge and belief, and no material information has been concealed or misstated. I further, state that if any inaccuracy is detected in the application, I shall be liable to forfeiture of any benefits derived and other action as per law.

______________
(Signature or left thumb impression of
person with disability, or of his/her legal
guardian in case of persons with mental
retardation, autism, cerebral palsy and
multiple disabilities)

Date:

Place:

Encl:

  1. Proof of residence (Please tick as applicable)
  2. ration card,
  3. voter identity card,
  4. driving license,
  5. bank passbook
  6. PAN card,
  7. passport,
  8. telephone, electricity, water and any other utility bill indicating the address of the applicant,
  9. a certificate of residence issued by a Panchayat, municipality, cantonment board, any gazetted officer, or the concerned Patwari or Head Master of a Govt. school,
  10. in case of an inmate of a residential institution for persons with disabilities, destitute, mentally ill, etc., a certificate of residence from the head of such institution.
  11. Two recent passport size photographs

(For office use only)

Date:
Place:

Signature of issuing authority
Stamp



Last Updated on Monday, 09 January 2012 14:45
 

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