.GCPP. 155/9--2,000 Cps; 29-6~2005. ANGANVADI CENTRE CODE: ANGANVADI CENTRE NAME: 1. NAME .'.. (surname) (first name) (middle name) 2. .3. FATHER/MOTHER/GUARDIAN NAME (As applicable) DATE OF BIRTH / AGE 4 SEX 5 WHETHER MARRIED 6 ADDRESS, .(Please mention permanent address and address for communication) PERMANENT ADDRESS ADDRESS FOR COMMUNICATION 7 EDUCATIONAL STATUS (Please indicate school and college attendance) 8 FAMILY INCOME: Rs. per annum (Note: Add income of all the earning members of the family living together in the same household) . 9 OCCUPATION (Describe here official designation and also hature of work performed by you) 10 REGISTRATION IN EMPLOYMENT EXCHANGEI SPECIA.L EMPLOYMENT EXCHANGEI VOCATIONAL REHABILITATION CENTRE (VRC) 10.1 Registration Number 10.2 Date of Registration 10.3 Name and address of employment exchange! Special Employment Exchange I VRC 11 IDENTIFICATION MARKS (i) (ii) 12. Blood Group 13. Nature of Disability (Indicate here the category of disability or diagnostic description of the disability as given in the medical certificate issued by designed medical board) 14, DEGREE AND PERCENTAGE OF DISABiliTY: 15. PARTICULARS OF MED1C'AL CERTIFICATE: (a) Medical authority issuing the certificate Date of Issue Whether disatility c~ndition is permanent or correctabl~ 16. SIGNATURE OR RIGHT/lEFT THUMB IMPRESSION OF PERSON 'WITH DISABiliTY OR lEGAL GUARDIAN FOR PERSONS WITH MENTAL RETARDATION, AUTISM, CEREBRAL PALSY & MULTIPLE DISABiliTIES (1) (2) (for office use only) 17. SIGNATURE AND STAMP Of AUTHORITY ISSUING THE DISABILITY CARD DATE SIGNATURE OF ISSUING AUTHORITY PLACE STAMP
