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Shit Soleil of Set Deaf Bi Ton Tae yee fegantin No eat st Hiae Ne ‘Wainer ent ter it Tie : il en RTT Wott isacwest so Ski denn 1 Mts {eh appli (oy hedapsh inher, > hth _ pe een in oi) perme ot Ahab vested Ia etn To Ber ——— [Conner and te of no he uses 9 pci). 2°" pent hr ssi olin ene spoof see (gat of bry) a6 per pods Tae of eee Davat ine | Da pati goa 7 Sig a sal fe edie Ran, oe. ) Oe esha wis eared by i (he Medel Oe (ois) aaa ison ft penn oes ner erent Sisal age 22.0125Form Ccrtteate of Disbisy (dn eases of tiple) (lame ad Adress ofthe Media Autboriy/Boed suing the Cerise) Rect papa se tested omg (Showing face on fof he peson Wid abi Cnet No. Das: This ist cetify tat we have caeilly xine ShriSmt/Kum soofvifdagher of Shi Date of Birh (DDINMIYY) Ae Painaeat resident of Hous No, WardVilapeSvee Ft Office District, a ‘whos polgrph i fied above anda atte that (Wy Hettie i's case of Muliple Disbiy.Hisher extent of, germane plysical npc iy has been eve spr guideline ( ruber aad dit of sue ofthe guidelines tobe specified forthe dsabies eked teow, and is shown aint the ‘ern ait in table Blow S.No] Dbl, ‘Aft — [Diogu | Pamaneat poi] pat tbody npuirmennenta sbi Gin) 1 [Rosemary 2. | Muar Dyrtopy 3. Leprosy ead 4 [Dwar 3. Cereal Fay z. 7. x 3. [Aci atick Vin Tove ion lidoes Desh (| Hard of earig | Speech ‘al ge db = TR | Ilan Dab | Specie Lean Disbity Te Ai Speci Dioner 15. | Ment nes 16] Chron Newroogea Coniteas age 23 0f25| Maile erase T TR Pskicson's disease 19, | Masmophiia t t 20. | Thaksin 1 21, | Sie Cell disease (@) i the Litt ofthe above hier ove all permanent physial giant as per guidelines {Cs -umbe and deo te ofthe pula to be pected), isa fellows: - Infiges percent Th wows ~ percent 2. This condition ie prgresivlno-progessveikely to ingroverot likely impove 5. Reatesmant of sai is: () aotaecesay, (i some Shab vai til — month, and therfre his cerfete ©) aon @ 0g, Letighutot armslegs Hog Single ee £ eg LefRighoth ews 4:The applicnt bas subsite The following documents proof of sdene:- Nae ofdocumeat ‘Date ofissue Details of ary” sung ceniiowe 5 Siar and sel of he Medial Autor. Nineand SalcfMenber | Nene aad Selo Mena [Name and Seal of te : Chairperson, I Cousosigned yt (Chie Medial Officer = (ithe) Signet impression othe person in whose Svan] Certifeat of eb fated Page 24 of 25Sovge sedan ied, thet belohe eo woe ot ‘Sa ENT Pep rained sr gins ("mum a ata me ie (lee si out te csites whic mot ppc) E eabore nian poeta oaretitfolmpovetit ely inpove Aiotneceney Cyicommendcuter yar, ‘Su be val (omaand Ey vce LetRignanat reas Ps sie eye eyer ecg Laatpebet months an hrfoe i coi seats coo age 25 0f 25