Re-certify *: Directions: Please fill in all necessary blanks on form (Including initials of person issuing card). When complete, please file in the box provided in alphabetical order. Name: Address: Telephone Number: Date of Birth: Hair Color: Eye Color: Height: Type of Disability: Certification Document From (Dr./Agency): Date Certification Issued: Signed By: Mobility Impaired: Description: Able to get to Bus Stop: Spring/Fall Only: Mobility Aid Used: Cane Walker Std. W/C Elec. W/C Pass Number: Person Issuing: Date of Re-Issue: Pass Number: Person Issuing: Pass Number: Person Issuing: * - Special I.D. cards must be re-certified 3 years after the date of last issue, or at any time a lost or damaged card is re-issued. Date of-Issue: Application Form for JTS Disabled Person Identification Card Issuance Platform ChairYESNO Published on National Portal of India (india.gov.in) Government of OrissaDepartment of Health & Family Welfare
