FORM OF APPLICATION FOR PHYSICALLY HANDICAPPED PERSONS FOR REGISTRATION OF NAME IN THE EMPLOYEMNT CELL
1. Name in full (In block letter)
a. Permanent address : At- Po-
b. Nationality :
c. Married / Un-married :
2. Name of Father / Guardian
a. Present address : At- Po-
b. Relationship with the guardian :
3. Name of physical handicap & its causes :
(with a short history)
4. Date of birth (In Cristian) :
5. Educational qualification & Vocational
Training (Attested copies of certificates
& Marksheets should be attached in
support of education training age etc) :
6. Whether the candidate has enjoyed any
scholarship stipend or any financial and
from State Central Govt. if so give details.
7. Whether the candidate has registered his her
name with employment Exchange or Spl.
Employment exchange for handicapped
If so, the No. & Date & Name of
Employment Exchange should be indicated :
8. Whether the candidate belongs to S.C / S.T
if so, attested copies of the certificates in its
support should be attached
9. Postal address to which communicated
should be sent.
Date: Signature of the Candidate
L.T.I. with attestation from
Gazetted Officer or P.S.
Chairman or Local MLA.
N.B (Please attach)
1. Three copies of attested Passport size photograph
2. One full size photograph showing portion of determining of the body.
3. Attested copy of Educational / Vocational certificates.
4. Attested copy of Nativity certificate.
5. Attested copies of Caste certificate.