Certificate For Physically Handicapped Candidate

 

Certificate For Persons with Disability (PwD) Candidate
(To Be Issued By Medical Board, General Hospital/Government Hospital)

 

1. Name of the candidate: Mr./Ms. _ _ _ _ _ _ _ _ _ _ passport photo
2. Father’s Name: _ _ _ _ _ _ _ _ _ _
3. Mother’s Name: _ _ _ _ _ _ _ _ _ _
4. Permanent Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
5. Percentage loss of earning capacity (in words): _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _
6. Whether the candidate is otherwise able to carry on the studies and perform the duties satisfactorily: _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ __ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ __ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _
7. Name of the disease causing handicap: _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _
8. Whether handicap is Temporary or Permanent: _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _
9. Whether handicap is progressive or non-progressive: _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _
10. The candidate is FIT / UNFIT to pursue the engineering/architecture studies.
(Strike out whichever is not applicable)
(Orthopaedic Specialist) Member Member Principal Medical Officer
Government/General Hospital
Date