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Certificate No.____________

Date____________

CERTIFICATE FOR THE PERSONS WITH DISABILITIES

This is to certify that Shri/Smt/Kum_____________________________________________________________Son/wife/ daughter of Shri____________________________________________________ Age _______ old male/female, Registration No.___________________ is a case of __________________________    He/She is physically disabled/visual disabled/ speech & hearing disabled and has______% (_______per cent) permanent (physical impairment/visual impairment/speech & hearing impairment) in relation to his/her ___________________________.

Note:-

      1. This condition is progressive/non-progressive/likely to impreove/not likely to improve.* 2. Re-assessment is not recommended/is recommended after a period of ____________ __________________months/years.*

*Strike out which is not applicable.

  Sd/- Sd/-    Sd/- (DOCTOR) (DOCTOR)                    (DOCTOR) Seal Seal    Seal

Signature/Thumb impression of the patient.

Countersigned by the Medial Superintendent/

CMO/Head of Hospital (with seal)

Recent Attested Photograph Showing the disability affixed Here.

STARDARD FORMAT OF THE DISABILITY CERTIFICATE

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