Department of Empowerment of Persons with Disabilities,

Ministry of Social Justice and Empowerment, Government of India

Acknowledgement / Resident Copy

Person with Disability Registration

Enrolment No: 0915/00000/2403/0146172 Enrolment Date: 04/03/2024

PERSONAL DETAILS

Name of Applicant Gori आवे दक का नाम गोरी

Applicant Father's Name Nihal Singh Applicant Mother's Name Ruma Devi

Date of Birth 01/12/2016 Age 7 Year(s)

Mobile Number 8937903040 E-Mail Id ---------

Gender Male Category General

Relation with PwD

Blood Group --------- Self
(Person with Disability)

Name of Guardian / Contact No. of Guardian /

Caretaker / Attendant / --------- Caretaker / Attendant / 8937903040
Related Related

Optional Details

Personal Income (Annual) Below 10000 Highest Qualification ---------

Employed or Unemployed ---------

Proof of Identity Card (See Instructions)

Identity Proof Aadhaar Card Aadhaar No. 626705199570

Address of Correspondence

Address Serab Agra, Bah, Agra, Uttar Pradesh - 283123

Nature of Document Aadhaar Card
for Address Proof

DISABILITY DETAILS

Do you have disability certificate? No Disability Type Mental Illness

Disability Area ---------
Disability Due To ---------
Hospital Treating State / UTs UTTAR PRADESH Hospital Treating District AGRA
Hospital Name General Hospital, Agra

This is computer generated receipt and does not require any signature.