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| | a Concession certificate form for orthopaedically handicapped/paraplegic person/patients/ mentally retarded person/ person with visual impairment with total absence of sight/ person with hearing and speech impairment totally(both afflictions together in the same person) Paste passport size photograph Duly signed and stamped by the issuing Doctor ‘This is to certify that Km/Shri/Smt. ‘whose particulars are furnished below is a bonafide ORTHOPAEDICALLY HANDICAPPED/ PARAPLEGIC PERSON/ PATIENTS WHO CANNOT TRAVEL WITHOUT THE ASSISTANCE OF AN ESCORT / MENTALLY RETARDED PERSON WHO CANNOT TRAVEL WITHOUT AN ESCORT/ PERSON WITH VISUAL IMPAIREMENT WITH TOTAL ABSENCE OF SIGHT / PERSON WITH HEARING AND SPEECH IMPAIRMENT TOTALLY (BOTH AFFLICTIONS TOGETHER IN THE SAME PERSON)* Particulars: a) Address: b) Father's/Husband’s Nam ©) Nature of Handicap: (To be written by doctor whether the disability is temporary or permanent) £) Signature or thumb impression of the person seeking concession ( not necessary for those with both hands missing or non-functional): (Signature of Government Doctor) Place: Date: Clear seal of Government Hospital# Seal containing full name and Registration Number of the Doctor *Strike out where not applicable. #For PERSON WITH VISUAL IMPAIREMENT WITH TOTAL ABSENCE OF SIGHT, RMP/Head of institution for the blind recognized can also issue certificate for visual impairment(with total absence of sight) 1) ‘The certificate should be issued only to those ORTHOPAEDICALLY HANDICAPPED/ PARAPLEGIC PERSON/ PATIENTS WHO CANNOT TRAVEL WITHOUT THE ASSISTANCE OF AN ESCORT / MENTALLY RETARDED PERSON WHO CANNOT TRAVEL WITHOUT AN ESCORTY PERSON WITH VISUAL IMPAIREMENT WITH TOTAL ABSENCE OF SIGHT / PERSON WITH HEARING AND SPEECH IMPAIRMENT TOTALLY (BOTH AFFLICTIONS TOGETHER). The photo must be signed and stamped in such ‘a way that doctor's signature and stamp appears partly on the photo and partly on the certificate. 2) For mentally retarded person’ PERSON WITH VISUAL IMPAIREMENT WITH TOTAL ABSENCE OF SIGHT / PERSON WITH HEARING AND SPEECH IMPAIRMENT TOTALLLY (BOTH AFFLICTIONS TOGETHER), the cerificato will be valid for five years from the date of issue. For temporary disability in the case of ortbopaedicaily/ paraplegic persons, the certificate will be valid for 5 years and in case of permanent disability, the certificate will remain valid for(i) five years, in case of persons upto the age of 25 years, (2) ten years, in case of ‘persons in the age group of 26 to 35 years and (3) in case of persons above the aige of 35 years, the certificate will remain valid for whole life of the concerned persons. After expiry of the period of validity of the certificate, the person is required to obtain a fresh certificaze, 3) Photocopy ofthis certificate is accepted for the purpose of grant of concession, ‘The original certificate will have to be produced for inspection atthe time of purchase of concessional ticket and during the journey, if demanded. 4) No alteration in the form is permitted. C)UseAdiniststonDeskton ec uldeORLTA\atisnts\consesi forms doek ‘reaper fare Ree seer gr wre afte gia & Reais cafenatainraes vo 3 sary cata wr efiederar ant eet raor site are fiat caftacen et eater A ahah srarrare ear ares) a fre Reva saroraa walt oct ae ae ae sleet vant fafa sr et eee Par re ot AR RT GT Tene are aT wich Reet ‘eng sraTV er pea AreTT BARS RATAN AMEE, manna nnnne eee Farrar fearor Ary fee aren f are HE PgR Rroaimtareréer eafeattor 8, at Reon Reed apace a aerae a ane aft we awe ser emote cafe Got pee & fer ara afl ee Twa pt wT a eRe cata got wr & ocr ait ow Gear cater Bewar Gt cater a aha srarsrart var are) ‘Prawn: *) 3) ™ a) x arr fra ae Rr sa ee a er 8) ——— a Rare oft Saft Ore a mr Fees Ses eo re Bt ae FRC SERA AEN): mn erat severe at ease ater ‘ahee Hat. aa qr any atte eisretet a. + o@t amy af Wt 58 are BL ff apt eRe eae ay Fae, areca Fae sara are gear a weer aft Recher as fate (pt efit ae rey wee snd ane eee Hh 1) 3m vores arr aR Reg Be Reeaimiorerer saRerart at Ren Reh eae A aera ar aft we amarante wr aoa eas, a ET Rar a a we HT CGE wT Se eRe alta pt wre re site res Bir wafer (ahah sessed), at neh Rar are efor wel oe eeTaRE athe AAC get TTA eT nity Pr staat 8 wears tte ate aR we A ww aTeT oer oe ste REE we -A ea ae at 2) eRRen er B anae cual! apt awe a eed saad pt wr a araur ite an ler cuttrat (Qt rare ap are), BF FRE a Ter ae oA ang hr at her at Be Fee area Bom ar Rep a Roni athe arriot afta arr areerty rere ke aE Tore § ah a Ne eer at athe ee sear ay amore a i TTT () 25 a aay ce A saat Ay arene HS at (2) 26 96 ah aR AAT ay TA at a Fae 10 af (9) 35 ah arts ang a care ay FRee ay everest caferdh a Gy stor & fw ae bam somone Fae arate ME A AF are, ear a aTaT wemOTeH wre awa ana I 9) Rarer 88 fBe gat sano sa AY WIAA A eae A are AE MOTT Rema Rowe A whe AF aT ate aner & ahs, HB ion oer 8, weg Ren oer sree ee 4) er TA A Fah rere er Petr Pe ome ay aa a BT sheverwte Tyee 207pofrmadiyenedece