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CERTIFICATE FOR THE PERSONS WITH DIS ABILITIES
This isto certifythatSri/SmUKum. . . . . . . Son/wife/daughterof Shri. . .
Age.... .. old, male/female, Registration No.. .. .. .. . isacasepf .... .
. He/she/ is physically disabled/visual disabled/speech & hearing disaled and has. . . .
. .Yo (.. . . .percent)
Permanent (physical imparment visual impairment speech & hearing
impairment) in relation to his/her. . . . . .
Note:
1. This condition is progressive/non- progressive/likely to improve/notimprove.
2. Re. assessment is not recommended/ is recommended of.monthly/years Strike out which is not applicable
likely to
(recent attestedphotographshowing Thedisability affixedhere)
Orthopedie/Eye/ENT/Phychiatrist
Member,Medical Board
SeniorSpecialistMember,
MedicalBoard
ChairpersonDistrict SurgeonDistrict Hospital
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