ANNEXTURE – D

APPLICATION FORM TO BE SUBMITTED BY HANDICAPPED PERSONS

UNDER SUPPLY OF SPECIAL AID SCHEME

  1.        Name of the applicant :

2.        Father / guardian’s name /age :-

3.        Permanent Address:-

4.        Male / Female:-

5.        Date of birth and age :-

6.        Monthly income of the Handicapped :

7.        Type of physical aid/appliance s recommended by

        a Govt. Medical Officer/ C.D.M.O. penal of specialist

8.        Date of application :-

9.        Whether student /unemployed /self-employed.

10.     Occupation /Field of self employment of father /

Guardian

11.     Details of disability.

12.     Declaration :-

                   I here by declare that all statement made in  this application are true complete and correct to the best of my knowledge and belief. In  the event of any information being found false or incorrect or ineligibility being detached before or after Providing the AID under special aid Scheme of the C.D. & R.R. Department action may be taken against me by the Govt. as dim fit.

Enclosures :- Medical and income certificate as

                        Prescribed on the declaration.

                                                                                                   Signature / L.T.I. of the Handicapped person

Receipt of Special Aid/Appliance

                I hereby certify that I have received the above aid appliance from the C.D.&R.R. Department supplied through ALImec . Fitment Centres / Hearing Aid centers

                I have received the aid in good condition.

If minor signature of                                                                                                                    Signature / L.T.I. of the

  Parent/ Guardian                                                                                                                           Handicapped person

Given the above special aid /appliance in my presence

                                                                                                                                 Signature / Name in Block letters

                                                                                                                                       Designation/Full address

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