32. APPENDIX -I
Application for issue Identity Card to
Physically Handicapped/Blind/Deaf in Private Buses
1 Name of Applicant :
2 Address :
3 Age & Date of birth of applicant :
4 Signature of the applicant :
(Space for Photograph)
5 Percentage of disability and details
(to be certified by the Medical Officer
Not below the rank of an Assistant
Surgan in the Orthopediac, Eye or ENT
Branch of a recognized Hospital) :
6 Name and Address of Medical Officer :
7 Signature of the Medical Officer with Date :
Sd/
Superintendent
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35. MEDICAL CERTIFICATE / DISABILITY CERTIFICATE
Certified that I have examined Sri/Smt/Kum....................................
whose
photograph is affixed and found that He / She
and also,
I certify that He/She is Mentally Retarded to the extent of Permanent disability up to....……
...................................................................................................................%............................
Identification Marks: 1
2
.........................................
..........................................................................................................................................
..........................................................................
....................................................................................................................................................
Designation of Doctor
Affix Office Seal on the Photograph Countersigned by……………...……….
Superindentend of the Institute
Name of Hospital……………………..
Date…………
Place………..
photograph
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58. MEDICAL CERTIFICATE FOR AVAILING FINANCIALASSISTANCE
FOR TREATMENT
(Tobe issued by the head of the hospital where the patient undergone treatment)
1.Nameandaddress ofthepatient :
2. Order no: with date of Registration/Admission :
3. Description of disease :
4. Treatment recommended :
5. Expenditure already incurred, if any :
6. Anticipated expenditure of the treatment
Undergoing/recommended :
7. Remarks :
Signature and name of the Issuing authority
Name and address of the hospital
Date:
(seal)
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61. CERTIFICATE
CertifiedthatSri..........................................................................................................................
And Smt
Place: Name:
Date: Designation:
(GazettedOfficer)
(seal)
....................................................................................................................................................
.....................................................................................................................................
........................................................................................................................(Name &Address
of the husband and wife)seeking financial assistance under the schemes of payments of grant to
persons placed under hard circumstance due to inter-caste marriage are personally known to me
andthattheyarelivingtogetherashusband&wifefornotlessthanoneyear.
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65. 65
ASWASAKIRANAM SCHEME
CERTIFICATE FOR BED RIDDEN PATIENTS
Place :
Date :
This is to certify that I have examined Shri /Smt /Kumari/ Master
....................................................................................................................................................
.........................................(Name and address of the applicant) aged .................... years on
(............................. Date). He /She is having ........................... % (......................................)
(Percentage in words) of Permanent / Temporary disability and is bed ridden / needs a full time
caregiverdueto..........................................................................................................................
Identification marks of the applicant
1.
2.
Name of the Doctor ...................................................................................
Registration No.
Name of the Hsopital
Signature and Seal To,
EXECUTIVE DIRECTOR
KERALA SOCIAL SECURITY MISSION
POOJAPPURA
THIRUVANANTHAPURAM
Thump impression of the patient
PHOTO
of bedridden
patient
attested
by Doctor