1. Name of the candidate:	Mr./Ms. _ _ _ _ _ _ _ _ _ _
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.
11.
(Strike out whichever is not applicable)
Member Member Principal Medical Officer Government/General Hospital
Date

1. _________________________________ 3. Permanent Address:______________________________ ______________________________________________ ______________________________________________ 4. : __________________________________________________ 4. _________________ 5. _____________________ 6. ________________ 8. ____________________ 9. _________________________ _________________________ __________________________ (Orthopaedic Specialist) General Hospital, Sector 16, Chandigarh Date: