APPLICATION FORM OF PHYSICALLY HANDICAPPED PERSONS

FOR ISSUE OF IDENTIFY CERTIFICATE

1. Name in full

( In block letters)

            (a) Permanent address-

                   At -                                                  P.O.                                                                         Via –

                   P.S. -                                                Block/Municipality                                               Dist -

            (b)                  Nationality –

            (c)                  Married/ Unmarried

2. Name of Father /Guardian –

            (a)  Permanent address

                    At -                                                                 P.O.                                                          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.

                                                                                         Signature /L.T.I. of the candidate, with attestation

        Date:                                                                        from any Gazetted Officer or Panchayat Samiti

                                                                                          Chairman or Local M.L.A.