APPLICATION FORM OF PHYSICALLY HANDICAPPED PERSONS

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.