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This is to certify that Kum/Shri/Smt
___________________________________________________
whose particulars are furnished below, is a bonafide* Orthopaedically
Handicapped/Paraplegic Person/Patient and CANNOT TRAVEL WITHOUT THE
ASSISTANCE OF AN ESCORT.
Particulars of Orthopaedically Handicapped/Paraplegic Person/Patient:
a) Address:
b) Father’s/Husband’s Name:
___________________________________________________________
c) Age: __________ d) Sex: __________
e) Name of Handicap: (To be written by doctor whether the disability is
Temporary or Permanent)
______________________________________________________________________________________
________________________________
f) Causes of loss of functional capacity: ______________________________________________________
__________________________
g) Signature or Left Hand Thumb : ________________________________________
Impression of Orthopaedically Handicapped/
Paraplegic Person/Patient (not necessary for those
whose both hands are missing or non-functional).
————————————————
(Signature of the Government Doctor)
Place : _______________________
Date : _______________________
___________________________
__________________________ Clear seal of
Government
Seal containing full name and
Hospital/Clinic.
Regn. No. of the Doctor.
Note: 1) The certificate should be issued only to those
Orthopaedically Handicapped/Paraplegic Person/Patient WHO CANNOT TRAVEL
WITHOUT THE ASSISTANCE OF 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) In the case of temporary disability, the certificate will be valid for
five years from the date of issue. In the case of permanent disability, the
certificate will remain valid for (i) five years in case of persons upto the
age of 25 years, (ii) ten years, in case of persons in the age group of 26 to
35 years and (iii) in the case of persons above the age of 35 years, the
certificate will remain valid for whole life of the concerned persons. After expiry
of the period of validity of the certificate, the person is required to
obtain a fresh certificate.
3) A Photostat copy of this certificate is accepted for the purpose of grant
of concession. The original will have to be produced for inspection at the
time of purchase of concessional ticket and during the journey, if demanded.
4) No alteration in the form is permitted.
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