GCPP .-155/5-2,000 Cps.-(G 17)-18"'8- 2006. APfENDlX 'A' No. Dated Affix a passport size ph-otograph of the applicant PART-.,;I physically1, Name and full address of the handicapped person 2. Nature of physical handicap 3. Occupation (State whether a Central Govern- ment employee or not) ... 4. Place of duty and approximate distance in kilometres from residence to the place of duty. . 5 Registration No. of vehicle and its Horse Power .. 5. Name and address of the driver who will drive motorised vehicle of a blind person and his motor driving licence No., etc. .. 7 AddresS and location of the dealer from whom the applicant wishes to purchase his require- ment of petrol/diesel. .. This is Certified that I, Sjo., Dfo., Shri ~- --am not in receipt of any allowance from State or Votuntary source for the purpose for which subsidy on purchase of petrol/diesel is meant and also certify that my income from all sources does not exceed Rs. 2,500 p.m. Signature of the applicant. PART-II 1. Registration No. of the vehicle 2. Monthly entitlement of petrol/diesel concessional rate 3. Vehicte.of 2 H. P. and below Vehicle of more than 2 H. P. at ... 15 litres p. m. 2S litrea p. m Signature of District Social Welfare Officer/Director of Social Welfare or his nominatedrOfficer/Officer Commanding of the rank of Major for serving Defence personnel/Tabsildar. District ---'--- --Dated i FO RM -II NATIONALITY jCOM MUNI TY /~ESIDEN~E/INCOME CERTIFICATE (To be obtained from t,he Revenue Department) --wife/son/daughterof -- This is to Certify that Tm\.1 Tbiru/Selvi --residing at-- ~--- is a native/resident of the Union territory of Pondicherry by virtue of his/her birth/continuous residence of not less than five year. He/she belongs to Scheduled Caste/Scheduled Tribe Community. His/her or his/her parent's/husband's anual income is Rs. Place: Date: Signature of the Tahsildar/Deputy Tahsildar with office seal. -Note: Please strike out which is Dot applicable.
