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 APPENDIX – A
FORM OF CERTIFICATE FOR ORTHOPAEDICALLY HANDICAPPED (LOCOMPOTOR DISABLED)
CANDIDATE FOR ADMISSION TO FIRS TYEAR DIPLOMA ENG. COURSES IN GOVERNMENT /GRANT IN
AID / SELF FININCEING INSTITUTIONS IN GUJARAT STATE

[ORTHOPAEDICALLY HANDICAPPED (LOCOMPOTOR DISABLED) ARE THOSE WHO HAVE PHYSICAL

DEFECT OR DEFORMITY WHICH CAUSE AN ISTERFERENCE WITH THE NORMAL FUNCTIONING OF
BONES, MUSCLES AND JOINTS]

(1) Full name of candidate :

(2) O.P.D. Case No. :
(3) (a) Nature of disability :
(to be mentioned in the square on the right side)
POLIO
CEREBRAL PALCY
HEMPLEGIA
PARAPLEGIA
QUADRUPLEGIA
AMPUTATIONS
COMGENITAL & ACQUIRED DEFORMITY
OTHERS

(b) Extent of disability :

( to be mentioned in the square on the right)
ON ANATOMICAL FUNCTIONAL
[PATIENT’S ASSESSMENT] [EXAMINER’S ASSESSMENT]
ECONOCICAL BASIS MENTIONED AS PERCENTAGE
BELOW 40% / 40% TO 60% / TOTAL DISABILITY

(4) Despite of the disability whether candidate is fit to undergo YES/NO

Engineering education and is able to discharge his duties
An engineer / technician thereafter
(Please state YES or NO in the square on the right side)

I certify that Shri / Kum. ____________________________________has been examined by me Dr

__________________________Orthopedic Surgeon on / /2005, and has been found orthopedic ally
handicapped ( Locomotors Disable) and in my opinion, he/she is in a position to undertake engineering course
and perform the functions of at least an engineer/ technician.

Out ward no. : Signature of Orthopedic Surgeon

Medical Superintendent / Civil Surgeon
Date: Govt. Hospital (Dist. & Gujarat State)

Round STAMP
Seal

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;FDFgI D[ZL8,L:8DF\YL VF5JFDF\ VFJGFZ K[P
!P! V5|tI1F VNIIG 5|âlT sDISTANCE s LEARNING MODE) :
VF 5wWlT C[9/ X~ SZ[, lJlJW l0%,MDF\ VeIF;S|DF[DF\ NFB, YI[, lJnFYL¶V[ VeIF;S[gN= BFT[ YLIZLGF TF; EZJFGF ZC[X[ GCL\P 5Z\T] T[G[ T[ HFT[
JF\RLG[ ;DHL XS[ T[J] NZ[S lJQFIG]\ BF; 5|SFZG]\ VwIIG ;FlCtI O|L VF5JFDF\ VFJX[P
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SD .g0SXG SFI¶S|D ZFBJFD\F VFJX[P T[DF\ lJnFYL¶G[ VeIF;S|D4 5ZL1FF4 5|FIMlUSSFI¶4 U''CSFI¶4 ;+SFD4 JS¶XM5 JU[Z[ V\U[GL DFlCTL VF5JFDF\ VFJX[P
T[DH VFH SFI¶S|DDF\ lJnFYL¶V[ E6JFGF\ lJQFIMGL GM\W6L SZFJJFGL ZC[X[P T[YL pD[NJFZ[ 5|J[X D[/jIF 5KL GSSL SZ[,F lNJ;[ VeIF;S[gN= BFT[ CFHZ
ZC[J] s OZHLIFTf K[P VF VeIF;S|DGL ;FY[ lJnFYL¶ 5MTFGM ALHM sVgIf l0%,MDF\ l;JFIGF VeIF;S|D RF,] ZFBL XSX[P NFPTP WMP!Z4 BSC,
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lJnFYL¶VMG[ VF5JFDF\ VFJ[,\ BF; 5|SFZG]\ ;FlCtI lJnFYL¶V[ TASSFJFZ HFT[ JF\RL4 ;DHLG[ T[GL ;FY[ VF5JFDF\ VFJ[,] U'CSFI¶ T{IFZ SZJFG]\ ZC[X[P VF
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SMQF¶ slJQFIf DF\ lGIT SZ[,F lX1FS âFZF T5F;JFDF\ VFJX[ VG[ T[DF\ H~ZL GM\W JU[Z[ SZLG[ lJnFYL¶G[ 5ZT DMS,JFDF\ VFJX[P lJnFYL¶V[ ;DI5+S 5|DF6[
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lJnFYL¶VMGL 5ZL1FF ;FY[ H4 H[ T[ lJQFIGF ;DFG 5|z5+MYL NZ[S ;+GF V\TDF\ ,[JFDF\ VFJX[ TYF 8[SGLS, 5ZL1FF AM0¶4 U]HZFT ZFHI NJFZF l0%,MDF\
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C:\website\MAHITIPUSTIKA\MAHITI.doc
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