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CERTIFICATE FOR PHYSICALLY HANDICAPPED CANDIDATE

Certificate For Physically Handicapped Candidate
(To Be Issued By Medical Board, General Hospital/Government Hospital)

1. Name of the candidate:Mr./Ms. _ _ _ _ _ _ _ _ _ _passport photo
2. Father’s Name:_ _ _ _ _ _ _ _ _ _
3. Mother’s Name:_ _ _ _ _ _ _ _ _ _
4. Permanent Address:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
5. Percentage loss of earning capacity (in words):_ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _
6. Whether the candidate is otherwise able to carry on the studies and perform the duties satisfactorily:_ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ __ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ __ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _
7. Name of the disease causing handicap:_ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _
8. Whether handicap is Temporary or Permanent:_ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _
9. Whether handicap is progressive or non-progressive:_ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _
10. The candidate is FIT / UNFIT to pursue the engineering/architecture studies.
(Strike out whichever is not applicable)
(Orthopaedic Specialist) Member Member Principal Medical Officer
Government/General Hospital
Date

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