STANDARD FORMAT OF THE CERTIFICATE NAME AND ...
STANDARD FORMAT OF THE CERTIFICATE NAME AND ...
STANDARD FORMAT OF THE CERTIFICATE NAME AND ...
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<strong>ST<strong>AND</strong>ARD</strong> <strong>FORMAT</strong> <strong>OF</strong> <strong>THE</strong> <strong>CERTIFICATE</strong><strong>NAME</strong> <strong>AND</strong> ADDRESS <strong>OF</strong> <strong>THE</strong> INSTITUTE/HOSPITAL issuing the certificateCertificate No…………………………….DATE :-…………………….<strong>CERTIFICATE</strong> FOR <strong>THE</strong> PERSON WITH DISABILITESThis is to certify that Shri/Smt/Kum………………………………………………………….Son/wife/daughter of Shri ……………………………………………………………………………Age………………………….old male/female, Registration no ……………………….. is a case of……………………………………………………………………… ……………………….. He/Sheis Physically disable/visual; disable/speech and hearing disable and has …………………………%(………………………. Per cent) permanent (physically impairment/visual impairment/Speech andhearing impairment) in relation to his/her…………………………………………………………….Notes;-1. This condition is progressive/non-progressive/likely to improve/not likely to Improve.*2. Re –assessment is not recommended /is recommended after a period of ………………months/years.*Strike out which is not applicable.Sd/- Sd/- Sd/-(DOCTOR) (DOCTOR) (DOCTOR)Seal Seal SealSignature/Thumb impression of the patient.Countersigned by theMedical superintendent/CMO/Head of hospital (with seal)Recent attested photograph showing thedisability affixed here.S.G.P.G.-01/SJEWD/2000 CPS/16.6.08
GOVERNMENT <strong>OF</strong> SIKKIMSOCIAL JUSTICE, EMPOWERMENT <strong>AND</strong> WELFAREDEPARTMENT(SOCIAL WELFARE DIVISION)GANGTOKPhotographAPPLICATION FOR OBTAINING DISABILITIES CARD.1. Name………………………………………………………………………………………………(Surname) (First Name) (Middle Name)2. Father’s/Husband’s Name ………………………………………………………………………..3. Date of Birth ………………………………………………………………………………………4. Sex ……………………….………………………………………………………………………..5. Caste .………………………………………………………………………………………….…..(Please state if you are belong to SC, ST, OBC or MBC categories)6. Address: State here permanent address for communicationGram Panchayat Unit No. and Name ………….…………………………………………………..Name of Ward …………………..…………………………………………………………………Constituency ………………………………………………………………………………………Sub Division …………………..…………………………………………………………………..B.D.O. …………………..…………………………………………………………………………Post Office …………………….…………………………………………………………………..District ……………………………………………………………………………………………..7. Family income………………………………………………………………………(Note: add income of all the earning member of the family living together in the samehousehold)8. Occupation ………………..……………………………………………………………………….(Describe here official, designation and also nature of work performed by you).9. Identification marks:-(1) ………………………………………………………………….………….(2) ……………………………………………………………………………..10. Nature of disabilities………………………………………………………………………………(Indicate here the category of disabilities of diagnostics description or the disability is given inthe medical certificate issued by designated medical board)
11. Degree of Disability ……………………………………………………………………………..(In case of locomotive disability, indicate percentage of disability in the case of MentalRetardation, mention here severity of disability if indicated in the Medical Certificate given, andgive here the specific diagnostic category indicating the degree of disability such asInternational Classification of Diseases code number).12. Particulars of Medical Certificate:-(a)(b)Medical Authority issuing the Certificate.Whether disability condition is permanent or correctable.13. Signature and thumb impression of persons with disability:-(1) …………………………………………………………………………..(2) …………………………………………………………………………..Signature and stamp of authority issue the disability card:Date:Place:Signature of issue AuthorityStamp:(1) This application form can be used for obtaining disability card in case the original disabilitycard has been lost and duplicate disability card is required to be obtained or format ofapplication will remain the same.(2) Please attach four (4) nos. passport size photographs. One photograph be affixed on theapplication while the other photograph to be stapled along with the application form, thesecond photograph will be used for affixed on the disability card.(3) Please attach a copy of the Medical Certificate obtained by you from the authorized MedicalBoard constituted by the State Government.(4) Please attach Sikkim Subject/Identification Certificate.
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