APPLICATION FORM OF PHYSICALLY HANDICAPPED PERSONS FOR ISSUE OF IDENTIFY CERTIFICATE 1. Name in full ( In block letters) (a) Permanent addressAt P.S. (b) Nationality – (c) Married/ Unmarried 2. Name of Father /Guardian – (a) Permanent address At - P.O. Block/Municipality P.O. Via – Dist - Via (b) Relationship with the guardian 3. Nature of physically handicap and its cause ( with a short history ) 4. Date of birth ( in Christian era ) ( Attested copy of Matriculation certificate/ other educational certificate, If not matriculate should be attached ) 5. Educational Qualification and vocational training ( Attested copy of certificate and mark sheet should be attached in support of education training , age. etc. 6. whether the candidate has enjoyed any scholarship stipend or any financial aid from state/ central Govt. If so give details. 7. Whether the candidate has registered his /her name in the Employment Exchange or special Employment Exchange or handicapped, If so the NO. and date & Name of employment Exchange should be indicated. 8. Whether the candidate belongs to SC/ST . If so attached copies of the caste certificates be attached. 9. Postal address to which communication should be sent. Date: Signature /L.T.I. of the candidate, with attestation from any Gazetted Officer or Panchayat Samiti Chairman or Local M.L.A.
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