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2005, 6uood: 19.11.2005

CERTIFICATE FOR THE PERSONS WITH DISABITITIES

:Tl""::"**":::1:-:i::' - ;;. ";,;,:;:::::-:;ff::No ""............."'....:....'..' is a case of ...i................ He / She is physically disabled/visual disabled/speech &

hearing disabled and has

visual impairment speech & hearing impairment) in relation of his / her .........

Note:

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

(Recent AttestedPhotograph showingthe disabilityaffixed here)

sd/-(Doctor)(Seal)

sd/-(Doctor)

(Seal)

sd/-(Doctor)(Seal)

Countersigned by theMedical Su perintendent CMO/Head

of Hospital (with seal)

Signature / Thumb impression

of the disabled person

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Certified that Sri / Smt

permanent / temporary post

(Designation) in the Dept. of ..'......... from

appointed therein under the rules of recruitment.

the said post.

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CERTIFICATE TO BE FURNISHED BY THE STATE / CENTRAL GOW. SERVANTS

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holds a

under the State / Central Govt. as ...........

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Signature of the appointing authority

of the department / with name and seal.