Disability Form – आधार संस्था

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आधार संस्था

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Disability Form
Contact

Contact Us

PERSON WITH DISABILITY REGISTRATION FORM

(दिव्यांग व्यक्ती नोंदणी अर्ज)

1. Personal Details

Applicant Name *

Father's Name *

Mother's Name *

Date of Birth *

Age *

Mobile Number *

Email Address

Gender *MaleFemaleOther

Category *(*Attached caste certificate for OBC/SC/ST only)GeneralOBCST

Blood Group *O+O-A+A-B+B-AB+AB-

Marital Status *MarriedUnmarriedWidowDivorcedDivorcee & Widower

Name of Guardian/ Caretaker/Attendant/Related Person:

His Contact No

Relation with person with DisabilityFatherMotherWifeHusbandUncleAuntySisterOther

Educational Details *PrimaryMiddle/Higher PrimarySenior SecondaryHigher SecondaryDiplomaGraduatePG DiplomaPost GraduateDoctorate

2. Address Details

Correspondence Address *

City

State/Province

ZIP / Postal Code

Country

Document for Address Proof *Driving LicenceRation CardVoter IDOther (Domicile Certificate)

Upload Document

No file chosen

3. Disability Details

Have Disability Certificate *(If Yes, Please fill in the following details & disability certificate)YesNo

Disability Certificate *

No file chosen

Unique Disability ID (UDID) Card Upload *

No file chosen

Details of Issuing Authority *Chief medical OfficeMedical Authority

Disability Type *BlindnessMuscular DystrophyHearing ImpairmentHemophiliaLow visionParkinson's DiseaseIntellectual DisabilityThalassemiaLeprosy CuredSickle Cell DiseaseAcid Attack VictimLocomotor DisabilityCerebral PalsyDwarfismMental IllnessMultiple SclerosisSpecific Learning DisabilitiesSpeech and Language DisabilityAutism Spectrum DisorderChronic Neurological ConditionsMultiple Disabilities Including Deaf Blindness

Disability Since *(in year)

Disability Area *ChestEarHeadLeft EyeLeft HandLeft LegMouthNoseShoulderThroatRight EyeRight HandRight LegStomach

Disability Due to *AccidentCongentialHereditary

4. Employment Details

Employed *YesNoUnemployed since

Occupation *Govt. jobProfessional/TechnicalAgricultureServices & ShopsClerksCraft/Trade WorkersDaily Wages WorkerPlant/FactoryOther Occupation

BPL/APL *N/AAPLBPLAntodya

Identity Details

Attached Identity ProofRation CardAadhaar Card

Aadhaar Card Number *

Consent *

Yes, I agree with the privacy policy and terms and conditions.

आधार संस्था, नागपूर

आधार संस्था विदर्भातील दिव्यांग व्यक्तींना कौशल्यविकास, रोजगाराच्या संधी, आणि कृत्रिम अवयव सहाय्याद्वारे समान संधी प्रदान करते. दिव्यांग व्यक्तींच्या स्वावलंबनासाठी आणि त्यांच्या उज्ज्वल भविष्याकरिता आपला हातभार लावा.

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Registrations

नोंदणी क्र. ८४१/११ (महाराष्ट्र)
CSR Registration number CSR00042569
80G Unique Registration Number AADAA7955NF20221

Our Contacts

sumittate911@gmail.com
+91 90119 19605
A-57, Shaktimata Nagar, Pandan Road, Nr. Kharbi Square, Nagpur, Maharashtra 440024