Concession Certificate for Persons with Disabilities Divyangjan)
Concession certificate form for orthopaedically handicapped/paraplegic personpatients/
mentally retarded person/ person with visual impairment with total absence of sight/ person with
hearing and speech impairment totally(both aflictions together in the same person)
Paste passport size
photograph
Duly signed and
stamped by the
0ssuing Doctor
This is to certify that Km/ShriSmt. whose particulars are furnished below is a
bonafide ORTHOPAEDICALLY HANDICAPPED/ PARAPLEGIC PERSON/ PATIENTS WHO
CANNOT TRAVEL WITHOUT THE ASSISTANCE OF AN ESCORT/MENTALLY RETARDED
PERSON WHO CANNOT TRAVEL WITHOUT AN ESCORT/ PERSON WITH VISUAL
IMPAIREMENT WITH TOTAL ABSENCE OF SIGHT /PERSON WITH HEARING AND SPEECH
IMPAIRMENT TOTALLY (BOTH AFFLICTIONS TOGETHER IN THE SAME PERSON)*
Particulars:
a) Address:
b) Father's/Husband's Name:
c) Age:
d) Sex:
e) Nature of Handicap: (To be written by doctor whether the
disability is temporary or permanent)
) Signature or thumb impression
oftheperson seeking concession (not necessary for those with
both hands missing or non-functionaly:
(Signature of Government Doctor)
Placo:
Date:
Clear seal of Government Hospital# Seal containing full name and
Registration Number of the Doctor#
*Strike out where not applicable.
#For PERSON WITH VISUAL IMPAIREMENT WITH TOTAL ABSENCE OF SIGHT,
RMP/Head of institution for the blind recognized can also issue certificate for visual
impairment(with total absence of sight).
1) The certificate should be issued only to those ORTHOPAEDICALLY HANDICAPPED/ PARAPLEGIC
PERSON/ PATIENTS WHO CANNOT TRAVEL WITHOUT THE ASSISTANCE OF AN ESCORT /
MENTALLY RETARDED PERSON WHO CANNOT TRAVEL WITHOUT AN ESCORT/ PERSON WITH
VISUAL IMPAIREMENT WITH TOTAL ABSENCE OF SIGHT /PERSON WITH HEARING AND SPECH
IMPAIRMENT TOTALLY (BOTH AFFLICTIONS TOGETHER). The photo must be signed and stamped in such
a way that doctor's signature and stamp appears partly on the photo and partly on the certificate.
2) For nentally retarded person/ PERSON WITH VISUÀL IMPAIREMENT WITH TOTAL ABSENCE OF
sIGHT / PERSON WITH HEARING AND SPEECH MPAIRMENT TOTALLLY (BOTH AFFLICTIONS
TOGETHER), the certificate will be valid for five years from the date of issue. For temporary disability in the case
of orthopaedically/ paraplegic persons, the certificate will be valid for 5years and in case of permanent disability,
the certificate will remain valid for () five years, in case of persons upto the age of 25 years, (2) ten years, in case of
persons in the age group of 26 to 35 years and (3) in case of persons above the age of 35 years, the certificate will
remain valid' for whole life of the concerned persons. After expiry of the period of validity of the certificate, the
person is required to obtain a fresh certificate.
3) Photocopy of this certificate is accepted for the purpose of grant of concession. The original certificate wil have
to be produced for inspection at the time of purchase of concessional ticket and during the journey, if demanded.
4) No alternation in the form is permitted.
CAUsers\AdministratorDesktop\Geetha folderGEETAPatients\concessio fons.docx
