ADMISSION FORM GOVT. TRAINING CENTRE FOR ADULT BLIND, SONEPAT (HARYANA) (SOCIAL DEFENCE & SECURITY DEPARTMENT HARYANA) Note:-Please read the form carefully and give correct in formation Score what is unnecessary? Non Residents of Haryana need not apply. 1. Name of Applicant (In Block Letters) _______________________________________ 2. Name of Father/Guardian _______________________________________ 3. Date of Birth (In Christian era) _______________________________________ 4. Religion_______________________5. Whether SC/BC________________________________ 6. Since how long you have been residing in Haryana_____________________________________ 7. Monthly Income of Father/Guardian with proof 8. Permanent Address 9. Present Address 10. Trade/Course in which admission issought by the applicant. 11. Previous Education/Training of Applicant: _________________________________________ Sr. No. Name of School Date of Joining Leaving Passed 12. Date of onset of blindness __________________________________________ 13. Cause of Blindness _________________________________________ 14. Degree of residual vision if any __________________________________________ 15. Other handicaps is any __________________________________________ (Enclosed blindness Certificate signed by Medical College Dr./Civil Surgeon/Eye Specialist in Govt. Hospital. Sign./Thumb Impression of applicant Dated....... .. Sign,/Thumb Impression of Father/Guardian of the applicant DECLARATION I hereby solemnly declare that the particulars mentioned above are correct to the best of my knowledge and belief. I further declares that the date of birth mentioned above of the applicant is correct & is in accordance with the date registered in M.C. Record or by village chowkidar. Sign,/Thumb Impression of Father/Guardian of the applicant Attestation of Gazzetted Officer Recommendation of :S.D.O. (C)/Tehsildar/B.D.P.O./City Magistrate/Distt. Social Welfare Officer for admission. Designation with Stamp.
