PROFORMA FOR SCRIBES
1. Name and Address of the scribe:
2. Date of Birth:
3. Details of educational qualifications/examinations appeared:
4. Specimen signature of the scribe:
5. Name and Register No of the student for which the scribe is appearing:
DECLARATION
I hereby declare that the information furnished above is true and that I have not qualified
/appeared for any examinations other than those mentioned in clause (3) above.
Place:
Date: Signature of scribe
Countersigned by the Principal
APPENDIX- A
Certificate regarding physical limitation in an examinee to write
This is to certify that, I have examined Mr./Ms./Mrs.____________________________(name
of the candidate with disability), a person (nature and percentage of disability as with
mentioned in the certificate of disability), s/o/D/o _ a resident of __________ (Village/
District/State) and to state that he/she has physical limitation which hampers his/her writing
capabilities owing to his/her disability.
Place: Date: Signature
Chief Medical Officer/ Civil Surgeon/ Medical
Superintendent of a Government health care institution & Designation. Centre with Seal
Name of the Medical Officer:
Name of Government Hospital/ Health Care
Note: Certificate should be given by a specialist of the relevant stream/ disability (e.g., Visual
impairment - ophthalmologist, Locomotor disability - Orthopaedic specialist/ PMRJ).
APPENDIX B
Letter of Undertaking for Using Own Scribe
I ______________________________, a candidate with _____________________ (name
of the disability) appearing for the_________________________________________ (name
of the examination) bearing Roll No. _________________ at________________________
(name of the centre) in the District__________________________________________(name
of the State). My qualification is ________________________________________________.
I do hereby state that (name of the scribe) will provide the service of scribe/lab assistant for
the undersigned for taking the aforesaid examination.
I do hereby undertake that his/her qualification is _________________________________.
In case, subsequently it is found that this qualification is not as declared by the undersigned
and is beyond my qualification, I shall forfeit my right to the post and claims relating thereto.
Place:
Date: (Signature of the candidate with Disability)