Appendix- 1/48
Concession Certificate for the purpose of Rail concession to Mentally Retarded Person
CONCESSION CERTIFICATE
Paste passport size photograph duly signed and stamped by the issuing Doctor/Person		Form for the purpose of grant of Rail concession to Mentally Retarded Persons to be used Government Doctor
This is to certify that Kum/ Shri/ Smt ___________________________________ whose particulars are furnished below, is a bonafide Mentally Retarded Person and CANNOT TRAVEL WITHOUT AN ESCORT.
Particulars of the Mentally Retarded person:
a) Address :
b) Father’s/Husband’s Name :
c) Age :
d) Sex :
e) Signature or Left Hand Thumb Impression of Mentally Retarded person :
			______________________________ (Signature of Govt. Doctor)
Place :
Date :
_____________________________ Clear seal of Government Hospital/ Clinic or Institution			______________________________ Seal containing full name and Regn. No of the certificate issuing Doctor.
Note:
1.	Certificate should be issued only to those Mentally Retarded Persons WHO CANNOT TRAVEL WITHOUT AN ESCORT. The photo must be signed and stamped in such a way that Doctor’s signature and stamp appears partly on the photo and partly on the certificate.
2.	The certificate is valid for five years from the date of issue. After expiry of the period of validity of the certificate, the person is required to obtain afresh certificate. A Photostat copy of this certificate is accepted for the purpose of grant of concession. The original certificate will have to be produced for inspection at the time of purchase of concessional ticket and during the journey, if demanded
3.	No alteration in the form is permitted.