Person with Disability Registration Form

PERSON WITH DISABILITY REGISTRATION FORM

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1. Personal Details

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Applicant Name :

Father’s Name :

Mother’s Name :

Date of Birth :

Mobile No :

Gender :

Mark of Identification :

First NameMiddle NameSurname

Age :

(DD/MM/YYYY)

E-mail ID :

MaleFemaleOther

Photograph

Passport Size 2 x 3

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Category :

Blood Group :

Marital Status :

Signature / Thumb / Other Print
General / OBC* / SC* / ST* / (*Attached cast certificate for OBC/SC/ST only)
O+ / O- / A+ / A- / B+B- / AB+AB-
Married* / Unmarried / Widow / Divorced / Divorcee & Widower

*If you are married give Spouse Name :

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Name of Guardian/ Caretaker / His/Her Contact No. :
/Attendant / Related Person :
Relation with Person with / Father / MotherWifeHusbandUncleAunty / SisterOther
Disability :
Educational Details : / Primary / Middle/Higher Primary / Senior Secondary / Higher Secondary
Diploma / Graduate / PG Diploma / Post Graduate
Doctorate

2. Address Details

Correspondence Address :

Pincode :
State/UTs : / District :
City/Sub District/Tehsil : / Village/Block :
Document for Address Proof :  Driving Licence / Ration Card / Voter ID / Other (Domicile Certificate)

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Permanent Address :

Pincode :
State/UTs : / District :
City/Sub District/Tehsil : / Village/Block :

3. Disability Details

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Have disability Certificate :

Sr./Reg. No. of Certificate :

Disability Percentage (%) :

Details of Issuing Authority :

Disability Type :

Disability By Birth :

Pension Card Number :

Hospital Treating Disability :

Disability Area :

Disability Due to :

Yes*No / (*If yes, please fill in the following details & attach disability certificate)
Date of Issue :
(DD/MM/YYYY)
(For example: 30%, 40%, 50%, 60%)
Chief Medical OfficeMedical Authority
Blindness / Muscular Dystrophy / Hearing ImpairmentHemophilia
Low Vision / Parkinson's Disease / Intellectual DisabilityThalassemia
Leprosy Cured / Sickle Cell Disease / Acid Attack Victim / Locomotor Disability
Cerebral Palsy / Dwarfism / Mental Illness / Multiple Sclerosis

Specific LearningSpeech and LanguageAutism SpectrumChronic Neurological

Disabilities / Disability / Disorder / Conditions
Multiple Disabilities including Deaf Blindness
Yes*No / Disability Since :
(in Year)
Disability Scheme :
Chest / Ears / Head / Left Eye / Left Hand / Left Leg / Mouth
Nose / ShoulderThroat / Right Eye / Right Hand / Right Leg / Stomach
Accident / Congenital / Hereditary

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4. Employment Details

Employed : / Yes / No* / Unemployed Since :
Occupation : / Govt. Job / Professional/Technical / Agriculture / Service & Shops
Clerks / Craft/Trade Workers / Daily Wages Worker / Plant/Factory
Other Occupation
BPL/APL : / N/A / APL / BPL / Antodya
Personal Income (Annual) : / Below 10,000 / From 10,000 to 1,00,000 / 1,00,000 to 5,00,000 / > 5,00,000
Father Income (Annual) : / Below 10,000 / From 10,000 to 1,00,000 / 1,00,000 to 5,00,000 / > 5,00,000
Spouse Income (Annual) : / Below 10,000 / From 10,000 to 1,00,000 / 1,00,000 to 5,00,000 / > 5,00,000

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5. Identity Details

Attached Identity Proof : / Driving Licence / PAN Card / Ration Card / Voter ID / Aadhar Card
Identity Proof Number :
Aadhaar Card Number : / TIN (NPR) :
Any Other State/UTs ID : / Other State/UTs ID Value :
I / , the applicant do hereby declare that what is stated above is true to the
best of my own information and brief.
Date : / Applicant’s Signature/Thumbprint :

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