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I,'ORM OI CERTIFICATE'TO BE PRODUCED
BYOTFIER BACKWART) Ct A.SSITSAppLylNG
FORAPI'OINTMFNT TO POSTS UNDER.TFIE
COVEIiNMENI OF INDIA
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+ l lr,j ( o[,rihIion (SiI Lillr) Sclrcdulrd a:rstc\ Or cr. I q /b.
*Tho Comiilntiou (Sikkirn) Siheduled l'ribes Order, 1978.
*l1o Colsiiiudou (Jammu and I{aslu r) Sche.luled liibes
Otder',
,tBo.
*:llo Cor;iitntion (Scheduled Casles) Oders (AmoDd0reut) Act, 1990.
+l Lu a,'nsriruli,'r (SuleJrrled l r rl,c") Or Jer A nren,h,. r,r A, r. lqq l.
l
,l Lc aor\srirurion (Silrcdrrle,l l llhcsl Or,]cr S.{\,tlJ Artrrrrlr)rpr,r ,^rt
1!0
t.
I
I
2. i'*This certilicate is issuc'd or the tasis ot11ic SchcdLrlod Castes/SchedulcdrTribes Certilicate issued to Shri/Shr
. Iadrer/rnoihcr* o,f
i atli*.
of village,itorv
imafti/Kuma
r
*
1l Dijui,uDivi.iu
ol llrc Sr,rlc Urrrorr Tclrrtoryt
who belorg 10 ttre Castc/T[iber' which is recognized as a
Schodu1od CastrJscheduled Tribe* ir 1he Siate[lnion Tcuitory*... .. . ........
hsued by tlie.... .. .. ..., datod. . . .. ..
Slni/Sln
......
village/iown*
Shli/Sluiuratjri*/I(umari*. . ..
residc(s) ir
Division+ of dre Slale/Uniou Terrilory*
3.
I
naLily
and/or{' his/[er* Iarnily ordioll.. .. ... ...... Dishict/
of , ... ..
.
..
Signature........
Desigoatior.
(witl
llnoo... .....
Dute.
............ i
seirl
.
.. ..
.
ofoflico)
Stnto
U
o1r
'Icrritorv
NoIE.-Thc temr "Ortlir1arily rcsides" used tere will have dre
ir Sectior 20 of the RepteseDtttio[ of {he Peoples Ast, 1950.
same
miraniDg as
t
++
ll.JsL drl.r. tlc $orJ\ whrl'
Jr r I af!t,.rt,tr
\fliIcrL'lc in rl,r .r"F of \r-s.
lfiMhy
in!
sc-
20
Nd,s g/t)?l
i
S
ti
p.,so11"
,1," t,x!c ,,
8,:.1.J
,r.r,, or,e s.1r.
.
U
I
'1
\o
a=4r-T
/.A,111-s'-
i
L
ii
i
l
(3) APPENDICES
API'['iNDIX-l
-l-DISz\BILIIIY CIIRIIFICA]
Gr) ANNTTXURE
-
I
E
to O.M., dated 29-12-2005
NAMI] AND ADDRESS OF THts ]NSTITUTE / HOSPITAI,
Date........ . -.-..-
Certificate No.
"
slowurg the disairilily
duly atlesied by the
MedicalBolrd
iri
I i[
1,
iil
,,'l:
rl
,l
r!'
'!
.iri
lt: ,r
iI;.r
riii
i
",
'I'his is certified tbat Slui
i
rnark(s)
daughter of Sh
identihcation
of fbllowing categoryr
/ Snt. /
..
.
age
Kum.
..... ..
...........---
son
-
..... ....
sex
IJA-Borh inns
llllrcrc,l
l/
(&)
tnrprireJ redLll
Wealoess oI gtip
(lli)
BLA-Both legs and both amls affected
(iv) OL-One leg affected (r'ight ol lcft) (n) Impailed reaoh
(b) weakness o{gdp
(c)
I
(r,) OA-One amr affected
(a) Impairerl leath
(6) Weakacss of grip
(c) Ataxic
(vi) BII-StilTback and hips (Cannot si1 or stoop)
(vr'i) MW-Muscular weakress and linlited physical enduraDce.
Ataxic
Blinduess or Low Vision
(,) B-Bhld
(ii) PB-Paltially Blind
wife /
is sulfering Aom permalent disability
A. Locomotol or cerebral palsyl
(l) BL-Both legs atlecte.lbut Dol anns.
rirl
/
...... ......... . ... ..... .....
:
C. IIe2ring imprirmelrt
:
(i) Il-Deaf
(il) PD-Piutially
Deaf
(Delete the category, whichevcr i! rlot applicable)
2. This condition is ptogressive / Don-p;.ogr ess ive / likely to itnptove
IrLrt J,l.TlJ ro irrpr,,\, Re r,cc\ ir. nf ,irr ..:r'e i. ,,,, r.e"o ur..r, le,J is
rcrorrrnrerrd.d -frcl r f,erro,l of
yr-,r- ... ..
. r,ro rrh.. .
3. Percentage ofdisabiiity in his / her.case is . .. ..
pel ceni.
4. Sh. / Srnl. / KuDt. ...
.. mccts 1he following physical
requireuents lot discharge oftis / her.dulrcs:(r) F-can perform work by rranipulating with fingers.
Yes / No
(ii) PP-can perfonn wolk by pLillirg and pushing.
Yes / No
(//l)
L-can peiforn r.rork by lifiing.
Ycs / No
(n,
KC-can perforni wolk by loreeiing arcl cr.ouching.
Yes / No
(r,) B-can pelfolm rvor-k by bendrng.
(vr) S,can perlbrl11 work by sitting.
Yes / No
Yes / No
r ,,r)
ST "r,r pcrlurnr wor'L b1 .r:nJrr,g
(viri) W-can pellomr work by walking.
(rr) SE-can perforn work by scr:ltrg.
(;r) ll can pelfomr rvor'hby heariDg / speaking.
(.ir) RW-arr pFrtolm \^t,rI
l
'Dr.V, n.bcr I
Medical Board
No
Yes / No
Yes /
Yes / No
rrr,lulirrrrg.
IrJ reading
tDl.
..r
MerLrL-r
Medical Board
Yes / No
(Dr.
...... .. ... .)
Chairpcrson
Medical l:]oard
(hunleLtigtled bl, the
i,leliLol S pel'itie deht / CMO /
Head aJ Hospit(tl(1lrith tad[)
+
Sir il.e our
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