மா திற ைடயேயா அர ேப கள
பயண ேம ெகா ெபா ைணயாளைர,
உட# அைழ % ெச வத கான ம வ சா#றித)
மா திறனாள க நல (மா.தி.ந.2) ைற
அரசாைண (நிைல) எ-: 18 நா : 31.05.2010
ேதசிய அைடயாள அ.ைட எ-:………………………………………………………………………
ெப ள சதவத
/ மா திறனாள
ெச வ0/தி மதி/தி :………………………………….……………. எ#பவ அைன அர
ேப கள தன யாக ேம ெகா ள இயலா . எனேவ அவ த# ட# ஒ
ைணயாளைர (with Escort) அைழ ெச வத 4 த4தி5ைடயவ என
சா#றள 66பப7கிற .
மா திறனாள ம வ ைகெயா ப
ைகெயா ப ம பதி8எ-:
ம வமைன
9 திைர
Concession certificate form for Orthopedically Handicapped/Paraplegic person/patients/
Mentally retarded person/ completely Blind person/totally Deaf & Dumb person
Travelling from……………………………………………………………………….…………..
This is to certify that Kum./Shri/Smt……………………………………………………………………………..……………… whose particulars are
furnished below is a bonfide ORTHOPAEDICALLY HANDICAPPED / PARAPLEGIC PERSON / PATIENTS WHO CANNOT TRAVEL
WITHOUT ASSISTANCE OF AN ESCORT / MENTALLY RETARDED PERSON WHO CANNOT TRAVEL WITHOUT AN ESCORT /
COMPLETETELY BLIND PERSON / TOTALLY DEAF & DUMB PERSON*
Particulars
(a) Address …………………………………………………………………………
(b) Father’s / Husband’s Name …………………………………………………………………………
(c) Age …………………………………………………………………………
(d) Sex ………………………………………………………………………….
(e) Nature of Handicap : (To be written
By doctor whether the disability is
Temporary or Permanent …………………………………………………………………………..
(f) Signature or Thumb impression
of the person seeking concession
(not necessary for those with
Both hands missing or non-functional …………………………………………………………………………..
Place ……………………….. ……………………………………………………………
Date ……………………….. (signature of Government Doctor#)
………………………………………………………… …………………………………………………………………………………….
Clear seal of Government Hospital#) Seal containing full name and [Link] the Doctor#
*Strike out where not applicable.
#For Blind persons RMP / Head of the Institution for the Blind recognized can alson Issue certificate for Blind.
Note:-
1. The certificate should be issued only to those ORTHOPAEDICALLY HANDICAPPED / PARAPLEGIC PERSON / PATIENTS WHO CANNOT
TRAVEL EITHOUT THE ASSISTANCE OF AN ESCORT / MENTALLY RETARDED PERSON WHO CANNOT TRAVEL WITHOUT AN ESCORT /
COMPLETELY BLIND PERSON / TOTALLY DEAF & DUMBS PERSON. The photo must be signed and stamped in such a way that doctor’s
Signature and stamp appears party on the photo and party on the certificate.
2. For Mentally retarded persons / completely blind person / Deaf & Dumb persons (both affliction together) the certificate will be
valid for FIVE Years from the date of issue. For Temporary disability in the case of orthopedically / paraplegic persons the certificate
will be valid for 5 years and in case of permanent disability, the certificate will remain valid for (1) fiver years, in case of persons upto
the age 25 years, (2) ten years, in case of persons in the age group of 26 to 35 years and (3) in case of persons above the age 35
years, the certificate will remain valid for whole life of the concerned persons after expiry of the period validity of the certificate, the
person is required to obtain a fresh certificate.
3. Photocopy 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.
4. No alteration in the form is permitted.
53402950/15M/F