PERSON WITH DISABILITY REGISTRATION FORM

1. Personal Details

Applicant Name :
First Name Middle Name Surname

Father’s Name :

Mother’s Name : Photograph

Passport Size 2 x 3
Date of Birth : Age :
(DD/MM/YYYY)

Mobile No : E-mail ID :

Gender : Male  Female

Mark of Identification :
 Other
Signature / Thumb / Other Print

Category : General  OBC*  SC*  (*Attached cast certificate for OBC/SC/ST only)

ST*
Blood Group :  B+  B- AB+  AB-
Marital Status :  O+
  O-  A+ Widow
A-
 Divorced  Divorcee & Widower
Married* 
Unmarried
*If you are married give Spouse Name :

Name of Guardian/ Caretaker

/Attendant / Related Person : His/Her Contact No. :

Relation with Person with Father  Mother  Wife  Uncle  Aunty  Sister 
Disability :
Husband Other
Educational Details :
Primary Middle/Higher Primary Senior Secondary Higher Secondary
Diploma Graduate PG Diploma Post Graduate
Doctorate
2. Address Details

Correspondence Address :

Pincode :

State/UTs : District :

City/Sub District/Tehsil : Village/Block :

Document for Address Proof :

Driving Licence Ration Card Voter ID Other (Domicile Certificate)

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Permanent Address :

Pincode : State/UTs : District : City/Sub District/Tehsil :

Village/Block :

3. Disability Details

Have disability Certificate : Yes*  (*If yes, please fill in the following details & attach disability certificate)

No
Sr./Reg. No. of Certificate : Date of Issue :
(DD/MM/YYYY)
Disability Percentage (%) : (For example: 30%, 40%, 50%, 60%)

Details of Issuing Authority : Chief Medical Office  Medical Authority

Disability Type :
Blindness Muscular Dystrophy Hearing Impairment  Hemophilia
Low Vision Parkinson's Disease Intellectual Disability  Thalassemia
Acid Attack Victim Locomotor Disability
Leprosy Cured Sickle Cell Disease
Mental Illness Multiple Sclerosis
Specific
Cerebral Learning
Palsy  Dwarfism
Speech and Language
Disabilities Disability Autism Spectrum Chronic Neurological
Disorder Conditions
Multiple Disabilities including Deaf Blindness
Disability By Birth : Yes*  No Disability Since :
(in Year)

Pension Card Number : Disability Scheme :

Hospital Treating Disability :

Disability Area :
Chest Ears Head  Left Eye  Left Hand  Left Leg 

Nose Shoulder  Throat

Mouth  Right Eye  Right Hand  Right Leg  Stomach

Disability Due to :
Accident Congenital Hereditary

4. Employment Details

Employed : Yes  Unemployed Since :

No*
Occupation : Professional/Technical  Agriculture Service & Shops
Govt. Job Craft/Trade Workers Daily Wages Worker  Plant/Factory


Other
Clerks
Occupation

BPL/APL :
N/A APL BPL Antodya
Personal Income (Annual) :
Below 10,000 From 10,000 to 1,00,000  1,00,000 to 5,00,000 > 5,00,000
Father Income (Annual) :
Below 10,000 From 10,000 to 1,00,000  1,00,000 to 5,00,000 > 5,00,000
Spouse Income (Annual) : Below 10,000 From 10,000 to 1,00,000  1,00,000 to 5,00,000 > 5,00,000
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5. Identity Details

Attached Identity Proof : Driving Licence  PAN Card  Ration Card  Voter Aadhar Card
Identity Proof Number : ID

Aadhaar Card Number : TIN (NPR) :

Any Other State/UTs ID : Other State/UTs ID Value :

I , the applicant do hereby declare that what is stated above is true to the best of
my own information and brief.

Date : Applicant’s Signature/Thumbprint :

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