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Unique Disability ID Application Form

This document is a registration form for people with disabilities. It collects personal details like name, age, address, contact information, as well as disability-related information like type of disability, disability certificate details, employment status, and income. The form has 5 sections - personal details, address details, disability details, employment details, and identity details. It collects information to register individuals with disabilities and their relevant identification, contact, and disability-related information.

Uploaded by

elite6
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
3K views

Unique Disability ID Application Form

This document is a registration form for people with disabilities. It collects personal details like name, age, address, contact information, as well as disability-related information like type of disability, disability certificate details, employment status, and income. The form has 5 sections - personal details, address details, disability details, employment details, and identity details. It collects information to register individuals with disabilities and their relevant identification, contact, and disability-related information.

Uploaded by

elite6
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

PERSON WITH DISABILITY REGISTRATION FORM

1. Personal Details

Applicant Name :
First Name Middle Name Surname

Fathers Name :

Mothers Name : Photograph


Passport Size 2 x 3

Date of Birth : Age :


(DD/MM/YYYY)

Mobile No : E-mail ID :

Gender : Male Female Other

Mark of Identification :
Signature / Thumb / Other Print

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

Blood Group : O+ O- A+ A- B+ B- AB+ AB-

Marital Status : Married* Unmarried Widow Divorced Divorcee & Widower


*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 Husband Uncle Aunty Sister Other
Disability :

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* No (*If yes, please fill in the following details & attach disability certificate)

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
Leprosy Cured Sickle Cell Disease Acid Attack Victim Locomotor Disability
Cerebral Palsy Dwarfism Mental Illness Multiple Sclerosis
Specific Learning Speech and Language Autism Spectrum Chronic Neurological
Disabilities Disability 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 Mouth
Nose Shoulder Throat Right Eye Right Hand Right Leg Stomach

Disability Due to : Accident Congenital Hereditary

4. Employment Details

Employed : Yes No* Unemployed Since :

Occupation : Govt. Job Professional/Technical Agriculture Service & Shops


Clerks Craft/Trade Workers Daily Wages Worker Plant/Factory
Other 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 ID Aadhar Card
Identity Proof Number :

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 : Applicants Signature/Thumbprint :

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