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.