AIDS & APPLIANCES FORM

Name(required)

Candidate Image (required)

Father's Name

Mother's Name

Present Address

House No/Name of House Place State / U.T

Ph/ Mobile No.:

Email:

Permanent Address:

Date of Birth

Age:

House Hold Income(Income Certificate to be Attached):

Gender :
MaleFemale

IN Words Rs

Type of Disability:

Visually ImpairedMentally RetardedAutisticHearing ImpairedLeprosy CuredLocomotor DisabilityMultiple Disabilities

Educational Details (Passed):

Priority
No.
Details of the Device Required (Please fill as per priority if required more than one device)
1st

2nd
3nd

Note:- A separate examination certificate may be required from the hospital/doctor for some AIDS & APPLIANCES.I declare that above information are true to the best of my knowledge. If any information
furnished by me turns out to be false subsequently, my registration may be cancelled

Date:

Place:

Signature of Applicant/Guardian :


For office use only…..

Serial No. of Application

Application Receiving Date
Verified By
Referred to Organisation
Decision Yes/No.
Remarks (If Any)

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