ANDAMAN AND NICOBAR ADMINISTRATION DIRECTORATE OF SOCIAL WELFARE ----------------- APPLICATION FORM FOR GRANT OF FINANCIAL ASSISTANCE FOR REHABILITATION PURCHASE OF AIDS/APPLIANCES AND MEDICAL TREATMENT TO THE PERMANENT DISABLED PERSONS. 1. Name of the Applicant : One Passport Size Photo (in BLOCK LETTERS) 2 Father's Name/Husband' Name : 3. Sex : 4. Married/Unmarried/Widow : 5. Date of Birth : 6. Nature of disability with percen- : tage (Medical Certificate of disability to be enclosed). : 7. Permanent Address : 8. Present Address : 9. Employment Registration No. : 10. Category : 11. Religion : 12. Occupation : 13. Details of assistance received : from Govt./Local bodies/ autonomous bodies. 14. Details of a family members : Signature of Applicant Contd.on..2.. -2 - CERTIFICATE TO BE FURNISHED FROM A REVENUE AUTHORITY NOT BELOW THE RANK OF TEHSILDAR. Certified that Shri/Smti/Kum./Kumar.................. S/o, W/o/D/o ................. R/o ............ is permanent resident of Andaman and Nicobar Islands for more than 10 years at the time of making this application. Place: Date: Signature: Designation: Official Seal: (Verification on non-judicial stamp paper not less than Rs.2/-) AFFIDAVIT I, .................. S/o, W/o /D/o ..... .................. R/o ............... aged ..... Years for hereby solemnly affirm and declared that :- 1 The particulars given by me in the application are true to the best of my knowledge and belief. 2 I am not in receipt of any other financial assistance of grant from any other sources. 3. I will refund the entire amount of assistance to the Govt. in case the information furnished by me proves wrong at any time. Place: Date: DEPONENT.
