APPLICATION FORM. (O.P.D-I )
1. Name Male/Female.
3. Type of disability
6. Details of Relatives.
7. Father/Mother Husband/Wife.
Above statement is correct.
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.
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.
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 .
Primary Health Center.