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CassCaepy Peak 7 napmontte ton ath ce) Bho Fro 7. ped re Po oe ch cee) (sin FOR eUbaty [Sebo VOT i. Serer prate oo) g a {eee tk os ope) ‘gaye mer son ee pom hd mprreindes ini (estan sper ce ect - 2. _ hegre sats elton et rat achce ware oiocanen|-Cam alle)” Celt ay Soa ra aaa * — — : SaaS oT Ba ‘oe er (atc Unseen ern ann noe | assing | Secred | faa agen Me Fema ren of Hoe No a everest ‘Soe eid a hwn gue Pear ea elo o> ere tt ne aS oe tn ac pie (TESS Sa Rapa a naenatvememotarernsars (i Neiteg | [eee SIDES, oem ea yaad say et) ‘olor oar skecaon, my candies & table 1s pete. sl be Bud | [LOCH sy s picgecmeumeree fons ? 8 ercaeintece nc anetecemunate, (Fe ae taro bet aoe wer Oe Sn Fp eneeesr fo nates) mae sr neste ime Se EST rr mont " cece: 2 TS ay BRT Frama epee A? gE rwecpce Tpaemimnrcma nace 3 Reema a Ser ae mero eS SES Sg cg campman anata? RTO Empowerment snr "64 Single ayebom eyes. Sha SK ‘and Jor Wis ¢ her tamiy 52 Leighton oe sea og Pe Sarees COU airtime | De ts [Dan ebay Ban arise saan exes me i orate Felegitn comme momensi Socrea Shcorts (apart mr LeU o Dt Hag ey onminon Setar see rye comin ate rd Shee oe Reta Sonny cli tte te secre Sea AI a Simi mein etter‘Continued trom page 32 Formal Disability Certificate (in case other than those mentioned in Forans Ilan tt) (NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE) (See rule 4) Recent PP size Atested Photograph (Showing face only) of the person wih disability Cerificate No. Date: This is to cerlily that we have carefully examined Shri/Smt/Kum, soniwifeldaughter of Shri Date ofBith______Age_yeats, malelfemale aor MT YY) Registration No. permanent resident of House No. _~ WardiVillage? S85 Post Office — District Sab, ‘Whose photograph is affixed above, and AM saiised that helahe is a caso of disability, Higher extent of percentage physical mpairment/ disability has been evaluated as per guidelines (to be specified) and is shown against the relevant disability inthe table below-- 'S. ]Disability ‘Aifected [Diagnosis [Pormanent Physical No. Part of Body impairmonvmontal disability (in %) i. |Lecomater disabiny | @ [2._ [Low vision # [S__[Blindnoss Bath eyes la__[Rearing impairment | = [s.___|Mental retardation x [&_ [Mental iiness x (Please strike out the disabilities which are not applicable.) 2. This above condton progressive! nor-prcgressie/ Brey to improve not ikely toimprove 3. Reacsossment of dsabilty is Ui) not nocoseary, Or {i) is recommended! afor yoars months, and theroforo this cerficate shall be val a a) ~ @ = eg. LeftRight/both armsilegs: # “ea Single eyelboth eyes £ eg. LefURightboth ears: 4.__The appicant has submitted the folowing document as proof of residence [Nature of Document | Date of fssue | Details of authority issuing certificate (Authorised Signatory of notified Mexiical Authority) (Name and Seal) Countersigned {Countersignature and seal of the CMO/ Modical Superintondont! Head of Govem- ‘mont Hospital, n case the cortficato is issued by a medical authority who is not a government servant (with seal) ‘Signature! Thumb impression of disabled person Note 1 : In case this cerificate is issued by a medical authority who is nota government ‘servant, it shall be valid oniy if countersigned by the Chief Medical Officer of tie District” Note 2 : The principal rules ware published in the Gazette of India vide notification umber 0. 908(€), dated the 3st December, 1956. davp 10702/11/0244/1820 EN 46/52