GCPP .-155/3--,-500 Cp~.-'-28- 04, GOVERNMENT OF PONDI,CHERRY SOCIAL WELFARE DEPARTMENT APPLICATION FOR ISSUE OF MOTORISED TRI:-CYCLE TO PERSONS WITH DISABILITIES FORM-] Name of the Applicant and Identification Card Number. Name of the Father/Guardian 2. Address for Communication 3. Month[IJ Year IIIII Age rn Day CO 4 Date pf Birth/Age (Certificate to be enclosed) Male/Female5 Sex 6 Nationality Details of any other benefits availed so far from this Department. 7 Nature of Disability 8 Rs.9. Annual Income Details of any other benefits availed/ : Availing from this Department. , 10 Whether he/she belongs to SC/ST (Caste Certificate to be enclosed). Anganwadi Centre Name with Code Number near to your residence. 12. DECLARATION BY THE APPLICANTIPARENT/GUARDIAN 1, '.' " ' ".: ,"'...' hereby declare that the .particulars furnished above are correct and true to the best.of my knowledge and that I have not received any financial assistance for conveyance purpose from the Department of Social Welfare or from any other source. I have not suppressed 'any material information that makes m~ ineligible to' receive this Motorised Tri-cycle. I understand that the sanction to be issued on the strength of the above information is liable to be cancelled if it is found that the information' furnished by me is proved to be incorrect and false. Signature of the Applicant Signature of the Parent/Guardian. 3 FORM-II,To be obtained from the Revenue Department) NA TIONALITY I COMMUNITY I RESIDENCE I INCOME C~RTIFICA TE This is- to certify th~t- 'hiru/Tmt./Selvi, (i) son/daughter of residing at is a native/resident of the Union Territory of Pondicherry by virtue of hi,s/her birth/qpntinuous residence of not less than five years. (ii) He/She belongs to Scheduled Caste/Scheduled Tribe Community. His/Her (or) His/Her parent's Annual Income is Rs.(iii) Place Signature of the Tahsildar/Deputy Tahsildarwith Office Seal . DateNote: Please strike-out which is not applicable. 4 FORM-III [See rule 5 (2)] APPLICA TION-CUM-DECLARA TION AS TO PHYSICAL FITNESSName of the Applicant 2. Son/Wife/Daughter of 3. Permanent Address 4, Temporary Address (if any) Identification Marks (1) 5. (2) DECLARATION Do you suffer. from epilepsy or from sudden attacks or loss of consciousness or giddiness from any cause? Yes/No(a) Are you able to distinguish with each eye (or if : you hav.e held 'a driving licence to drive II. motor.vehicle for a period of not less than five years and if you have lost, the sight of one eye after the said period of five years and if the application is for driving a light motor vehicle other than a transport vehicl~ fitted with an outside mirror on the steering wheel side) or with one eye, at a distance 0(25 metres in good day light (with glasses if worn) a motor car number plate? (b) Yes/No 5 Have you lost either hand or foot or are you suffering from any defect or muscularpower of either arm or leg? "- Yes/Noc Can you readily distinguish the pigmentary colours, red and green? (d) Yes/No Do you suffer from night blindness?(e) Yes/No Are you so deaf as to be un~ble to hear (and if application is for Driving a Light Motor Vehicle, w'ith or without hearing aid) the ordinary sound . I ?sIgna. (f) Yes/No Do you suffer from any other disecase or disability likely to cause your driving of a motor vehicle to be a source of dang~r to the people if so give details. (g) Yes/No I hereby declare that to the best of my knowl~dge and belief, the particulars above the declaration made therein are true. Signature or Thumb-impression of the Applicant Note: (1) An applicant who answers 'Yes' to any of the questions (a), (c), (e), (f) and (g) or 'No' to either of the questions (b) and (d) should amplify his answers with full particulars 'and may be required to give further information relating thereto.. (2) This declaration is to be submitted invariably with Medical Certificate in Form-IlIA. 6 FoRM-IIIA [See rules 5 (1) (3), 7, JO (a), 14 (d) and 1.9,{d)] MEDICAL CERTIFICATE [To be filled in by a r~gistered Medical Practitioner appointed for the purpQse by the State Government or person authorised in this behalf by the State Government referred to under sub-section (3) of section (8)] Nam-e of the Applicant Identification Marks (1)2. (2) Does the applicant to the best of your judgement: suffer from any defect of vision? If so, has it been corrected by suitable spectable. Yes/No3. (a) Yes/No(b) Can the applicant to the best of your Judgement readily distinguish the pigmentary colours, red anQ green? In your opinion is he able to distinguish with his eye sight at a distance of 25 meters in good day light a motor car number plate? Yes/No(c) .In Y9ur opinion does the applicant suffer ~om a degree of deafness which would prevent his- hearing the ordinary sound signals? Yes/No(d) In your opinion does the applicant suffer: from night blindness? (e) Yes/No Yes/No(f) Has the applicant any defect or deformity or loss of member which would interfere .' with the efficient performance of his duties' as a driver? (g) ,If so, give your reasons in details OPTIONAL :(a) Blood Group of the applicant (If ths: applicant so desires that the infonnation may be noted in his driving licence). RH factor of the applicant (If the applicant so desires that the information may be given in his driving licence). .--(b) 7 DECLARATJON Made by the applicant in Fonn-I as to his Physical Fitness is attached trans I certify that I have personally exa~ined the applicant , , I also certify that while examining the applicant. I have directed special attention to the distance vision and hearing ability, the condition of the arms, legs, hands and joints of both extremities of the candidate and to best of my judgement, he is medically fit/not fit to hold a ~riving.licence.. The applicant is not medically fit'to hold a licence for the following reasons Signature Name and Designation of the: Medical Officer/Practitioner. 1 (Seal) Registration- Number of the Medical Ofijcer. . 2. Signature or Thumb-impression: of the Candidate. 3. Date The Medical Officer shall affix his signature over the photograph- affixed i~ a manner' that part of his signature is upon the photograph and p.art on the. certificate. Note: FORM-III A See rules 5 (1),(3)]
