Paste Passport size

Photograph duly
Signed and
Stamped by the
Issuing Doctor CONCESSION CERTIFICATE
Appendix-1/36
(See rule 101, Sl.No.25)

Form for the purpose of grant of rail concession to orthopaedically Handicapped/paraplegic

persons/patients to be used by the Government Doctor.

This is to certify that Sri/Smt………………………………………………………………………

Whose particular are furnished below, is a bonafied orthopaedically Handicapped /paraplegic persons
/patients and CANNOT TRAVEL WITHOUT THE ASSISTANCE OF AN ESCORT)

Particular of the orthopaedically Handicapped /paraplegic persons /patients:

A) Address…………………………………………………………………………………….….......
...................................................................................................................................

B) Fathers/Husbands Name…………………………………………………………………..

C) Age…………………. d) sex…………………………….

E) Nature of handicap (to be written by

Doctor whether the disability is
Temporary or permanent) ……………………………………………………………….
F) cause of loss of functional capacity………………………………………………………
G) Signature or left hand thumb
Impression of orthopaedically
Handicapped /paraplegic
Persons /patients (Not…………………………………………………………………….
necessary for those whose both hands are
missing or non functional)

Place……………………..
………………………………..
Date……………………… (Signature of the Govt. Doctor)

………………………………. ………………………………………
Seal of Govt. hospital/clinic (Seal containing full name and Reg. no
of Doctor)
Note:
1. The certificate should be issued only to completely blind person. The photo must be signed and stamped by the
certificate issuing Doctor/person in such a way that signature appears partly on the photo and partly on the
certificate.
2. The certificate valid for five years from the date of issue. After expiry period of validity of the certificate the
person is requested to obtain a fresh certificate. Photography of this certificate is accepted from the purpose of
grant of concession. The original certificate will have to be produced for inspection at the time of purchase of
concessional ticket and during the journey, if desired.
3. No alteration in the, form is permitted.