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Declaration Form

The document is a declaration form for beneficiaries of the Haryana Wheelchair Cricket Association (HWCA) receiving NeoMotion wheelchairs. It outlines the responsibilities and commitments of the beneficiary, including non-resale of the wheelchair, personal use for para-sports, and liability for any harm caused. The form also requires personal details and is to be filled out by an HWCA official for record-keeping.

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stephenhawkingao182
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2 views1 page

Declaration Form

The document is a declaration form for beneficiaries of the Haryana Wheelchair Cricket Association (HWCA) receiving NeoMotion wheelchairs. It outlines the responsibilities and commitments of the beneficiary, including non-resale of the wheelchair, personal use for para-sports, and liability for any harm caused. The form also requires personal details and is to be filled out by an HWCA official for record-keeping.

Uploaded by

stephenhawkingao182
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

PASSPORT

SIZE
PHOTOGRAPH
OF THE
BENEFICIARY

DECLARATION BY BENEFICIARY

I , _________________________________________________ , a player in Haryana Wheelchair Cricket


Association (HWCA), wish to declare as follows:
1. I declare that I have not received any NeoMotion wheelchair before in CSR.
2. I declare that the details, documentation and everything furnished to the assessment team is best to my
knowledge and I am not concealing anything from HWCA and NeoMotion team.
3. I declare that I would not be reselling or trading the NeoMotion’s NeoFly and NeoBolt that I would be getting
in CSR with the help of the HWCA as implementing agency.
4. I declare that I would be personally using the given NeoMotion’s NeoFly and NeoBolt for the purpose of
improving livelihood through para-sports and other related activities only. I would not be using the
wheelchair for any illegal or immoral purpose/activity.
5. I declare that if at any point of time in future, I do not use the given NeoMotion’s NeoFly and NeoBolt set, or
I leave my engagement with HWCA, I would responsibly give it back to HWCA to be given to some other
beneficiary who can use it responsibly for its assigned purpose/activity.
6. I declare that I would not do any activity that harms the pride, purpose and identity of NeoMotion company
and Haryana Wheelchair Cricket Association (HWCA).
7. I also declare that if in future, any harm is caused to me due to usage of the given set, I would be taking its
full responsibility on myself and would not be blaming either HWCA or NeoMotion.
8. I also declare that no charges of any sort are being taken from me for this NeoMotion’s NeoFly and NeoBolt.
9. I accept that all forms of legal action can be taken against me if I do not follow the mentioned points in my
declaration and I will take full liability of any harm caused if I do not follow this declaration.

NAME

ADDRESS

DATE OF BIRTH _____/_______/_________


GENDER Male / Female
AADHAR NUMBER
UDID NUMBER
CONTACT NUMBER
SIGNATURE

DATE

To be filled by HWCA official :


Place of Assessment :_____________________________ Serial Number : 2025-2026/_______________
HWCA official name : _____________________________ Documents received : YES / NO

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