ANNEXURE-VII

 

FORM OF APPLICATION FOR PHYSICALLY HANDICAPPED PERSONS FOR REGISTRATION OF NAME IN THE EMPLOYEMNT CELL

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1. Name in full (In block letter)

 

                a.                 Permanent address :                At-                                          Po-

                                                                                via-                                         P.S.-                                       

                                                                                Dist-                                       Municipality

 

b.                   Nationality                                :

c.                   Married / Un-married :

 

2.             Name of Father / Guardian

 

                a.                 Present address :                At-                                          Po-                                                                         

                                                                                Dist-

 

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.