Annexure-IX

APPLICATION FORM. (O.P.D-I )

1. Name Male/Female.

2. Age

3. Type of disability

4. Address

5. Occupation.

6. Details of Relatives.

7. Father/Mother Husband/Wife.

8. Son

Above statement is correct.

Place:

Signature/impression

Note:- Contents on the application should read to a blind, if a applicant and

certificate to this effect is furnished by Gazetted Officer.

Date/Place: - Signature of Gazette officer.

9. CERTIFICATE

I………………………………….B.D.O./Tahasildar have verified the applicant of village/ward/Municipality/ N.A.C./Ward found him/her to be disable. The content of the application are found to be correct to the best of my knowledge and belief.

Medical Certificate

Certified that Sri/Smt,,……………………………..S/O,D./O,W/O………………

Village……………..G.P…………………………Dist, Koraput is totally blind or orthopedic ally Handicapped and because of disability is…………………….

Medical Officer.

Primary Health Center.