| . | .. | ANNEXTURE – D
APPLICATION FORM TO BE SUBMITTED BY
HANDICAPPED PERSONS UNDER SUPPLY OF SPECIAL AID SCHEME 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. 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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