AIDS & APPLIANCES FORM

Name of Candidate(required)

Candidate Image (required)

Father Name

Mother Name

Present Address,h5>

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

Address Details:

Ph/ Mobile No.:

Email:

Date of Birth

Age:

House Hold Income(Income Certificate to be Attached):

Gender :
MaleFemale

IN Words Rs

Type of Disability:

Category :
GENERALOBCSCST

IN Words Rs

Language Details Proficiency in Language

Languages
Known
Read

Write Speak

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)

2014 trustcandle.com | Developed & Designed by WebnoTech | Privacy Policy | Terms & Conditions