APPLICATION FOR OBTAINING IDENTITY CARD FOR PERSONS WITH DISABILITIES 1. Name (surname ) (first name) (middle name) 2. Father/Mother/Gurdian Name (As applicable) 3. Date of Birth /Age : 4. Sex : 5. Whether Married : 6. Address (Please mention permanent address and address for communication) Permanent Address (a) Address for communication (b) 7. Educational status 8. Family Income : Rs (Please indicate school and college attendance) Name of School/ College/ professional institution Years of attendance Year of passing and certificate/ degree obtained. per annum (Note : Add income of all the earning members of the family living together in the same household) 9. Occupation : (Describe here official designation and also nature of work performed by you) 10. Registration in employment exchange/ : pecial employment exchange / Vocational rehabilitation centre(VRC) 10.1 Registration Number: 10.2 Date of registration: 10.3 Name and address of employment exchange/ Special Employment Exchange/ VRC 11. Identification marks (i) (ii) 12. Blood group: 13. Nature of disability : (Indicate here the category of disability or diagnostic description of the disability as given in the medical certificate issued by designated medical board) 14. Degree and percentage of disability: 15. Particulars of medical certificate (a) Medical authority issuing the certificate (b) Date of issue (c) Whether disability condition is permanent or correctable 16. Signature or right/left thumb impression of person with disability or legal gurdian for persons with mental retardation,autism,cerebral palsy & multiple disabilities (1) (2) (for office use only) 17. Signature and stamp of authority issuing the disability card. Date: Signature of issuing authority Place: Stamp NOTE : (1) This application form can be used for obtaining identity card for persons with disabilities. In case the original card has been lost and duplicate card is required to be obtained, the format of application will remain the same. NOTE : (2) Please attach two passport size photographs. One photograph be affixed on the application while the other photograph be stapled along with the application form, the second photograph will be used for affixing on the disability card. NOTE : (3) Please attach a copy of the medical certificate obtained by you from the authorized medical board constituted by the State Government/ Defense authorities.
