(Assistance to Disabled for Self Employment) APPLICATION FORM FOR THE GRANT OF ASSISTANCE UNDER THE SCHEME ASSISTANCE TO THE PHYSICALLY HANDICAPPED PERSON FOR SELF- EMPLOYMENT 1. Name of applicant (in block letter) ----------------------------------------------------- 2. Father's Name --------------------------------------------------------------------------- 3. Caste --------------------------------------------------------------------------------------- 4. Address ----------------------------------------------------------------------------------- 5. Age ---------------------------------------------------------------------------------------- 6. Present profession ----------------------------------------------- 7. Educational Qualification ----------------------------------------- 8. Purpose for which the assistance is required , with the amount of assistance required. 9. If any loan has been obtained form any bank or Govt. Institution give full particulars of the loan ------------------------------------------------------- 10. A Certificate from any govt. Hospital/Dispensary should be attached with regard to ----------------------------------------------------------------------------- 11. Percentage of disability.----------------------------------------------- 12. Income from all sources per Annum----------------------------------- 13. Location of place where the business has been proposed to be state with details of Facilities like shop, form etc, available----------------------------------------------- 14. Any other information ------------------------------------------------------------------- 15. Total estimated cost of the project ------------------------------------------ (Attached project report of scheme) I certify that the above information is correct to the best of my Knowledge and belief that nothing has been concealed. Signature of the applicant (Certificate is to be signed by the S.D.M./Gazetted Officer posted in the District). --------------------------------------Address ----------------------------------------------Certify that Sh.-------------------------S/O Sh.--------------------------------is personally known to me and that to the best of my knowledge and belief the content given in the above application are correct. Signature of the attesting authority Address ------------------------------ The applicant shall attach the following Certificate from Sub Divisional Magistrate/ Tehsildar/ Naib Tehsildar With his application ------------------------------- (1) Permanent Residence Certificate. (2) Income Certificate (3) Disability Certificate shall be attached indicating the nature and percentage of disability
