Wards : *
Circle No & Name : *
Zone :
Mandal : *
Assembly Constituency No & Name :
Name (Including Surname) : *
Father/Husband's Name :
Sex :
Date Of Birth : Age (In Years) :*
Blood Group :
Name to be Displayed on ID card : *
UID Number(If available) :
Full Address :
Pin code :
Mobile No : *
Email-Id :
Nationality :
Religion :
Caste : *
Martial Status :
Educational Qualification: *
Do you Possess Disability Certificate : *
Type of Disability Certificate : *
Disability Certificate No : *
Certificate issued by which Dist.Medical Board : *
Percentage of Disability : %*
Date of issue of Disability Certificate : *
Nature of Disability : *
Type of Pension receiving : *
Type of Ration Card : *
Ration Card No : *
Type of appliance Using :
Type of appliance Required :
Type of Surgery Undergone(if any) :
Type of Surgery Required(if any) :
Details of the house :
Occupational Status :
Whether intrested in any skill trainings : *
Member of Self Help Group of Disabled : *
If Yes,Write The name of the Self Help Group :
Benefits being availed :