• Applicant's Full Name *

• आवेदक का पूरा नाम*

  (Click on the text to see the suggestions / hints)

• Applicant Father's Name *
• Applicant Mother's Name *
• Date of Birth *

• E-Mail Id

  (email can be used upto only four application)
• Mobile Number

  (mobile number can be used upto only four application)
• Gender*

  Select Gender Male Female Transgender

• Category*

  Select Category General OBC ST SC Other
• Blood Group

  Select Blood Group O+ O- A+ A- B+ B- AB+ AB-

• Relation with Person*

  Select Relation with PwD Father Mother Wife Husband Uncle Aunty Sister Daughter Self Other Son
• Name of Guardian / Caretaker*
• Contact No. of Guardian / Caretaker*

• Photo *

  (Only jpeg, jpg and png image with size 15 KB to 100 KB allowed and Photo image Width and Height less than 800px allowed)
• 
• Signature / Thumb / Other Print

  (Only jpeg, jpg and png image with size 3 KB to 30 KB allowed)

Optional Details

• Personal Income (Annual)

  Select Personal Income Below 10000 From 10000 To 100000 100000 to 500000 > 500000
• Highest Qualification

  Select Highest Qualification Primary Middle/Higher Primary Senior Secondary Higher Secondary Diploma Graduate PG Diploma Post Graduate Doctorate Illiterate
• Employed or Unemployed

  Select Employed or Unemployed Employed Unemployed

Proof of Identity Card

• Identity Proof

  Select Identity Proof Aadhaar Card Address card with photo issued by Deptt. Of Posts, Arms License Cast and Domicile Certificate with photo issued by Certificate of address having Photo issued by MP/M Certificate of address with photo from Govt. recog Certificate of photo identity issued by Village Pa CGHS/ECHS Card Current passbook of Post Office/any scheduled bank Driving License Freedom Fighter Card having photo Income Tax PAN Card Kissan Passbook having photo Passport Pensioner Card having photo Photo Credit Card Photo Identity Card (of Central Govt./PSU or State Photo Identity Card issued by Govt. recognized edu Ration Card with Photo Smart card issued by CSD, Defence/ Paramilitary Sri Lankan Refugees Identity Card# Voter ID/Election Commission ID Card
• Upload Identity Proof *

  (Only jpeg, jpg, png and pdf with size 10 KB to 500 KB allowed)

• Aadhaar No.*
•  

  I agree to share Aadhaar information with Govt. Department.

• Nature of Document for Address Proof*

  Select Nature of Document Aadhaar card Address card with photo issued by Deptt. Of Posts, Govt. of India Arms License Cast and Domicile Certificate with address and photo issued by State G Certificate of address having Photo issued by MP/MLA/Group-A Gazetted Certificate of address issued by Village Panchayat head or its equival Certificate of address with photo from Govt. recognized educational in CGHS/ECHS Card Credit Card Statement (not older than last three months) Current Passbook of Post Office/any Schedule Bank Driving License Electricity Bill (not older than last three months) Freedom Fighter Card with address Income Tax Assessment Order Kissan Passbook with address Other (Domicile Certificate) Passport Pensioner’s Card with address Photo Identity Card having address (of Central Govt./PSU or State Govt Ration Card Registered Sale/Lease Agreement Sri Lankan Refugees Identity Card Telephone Bill of Fixed line (not older than last three months) Vehicle Registration Certificate Voter Id Water Bill (not older than last three months)
• Proof of Correspondence Address*

  (Only jpeg, jpg, png and pdf with size 10 KB to 500 KB allowed)

• Address*

• State / UTs*

  Choose State / UTs ANDAMAN AND NICOBAR ISLANDS ANDHRA PRADESH ARUNACHAL PRADESH ASSAM BIHAR CHANDIGARH CHHATTISGARH DADRA NAGAR HAVELI AND DAMAN AND DIU DELHI GOA GUJARAT HARYANA HIMACHAL PRADESH JAMMU AND KASHMIR JHARKHAND KARNATAKA KERALA LADAKH LAKSHADWEEP MADHYA PRADESH MAHARASHTRA MANIPUR MEGHALAYA MIZORAM NAGALAND ODISHA PUDUCHERRY PUNJAB RAJASTHAN SIKKIM TAMIL NADU TELANGANA TRIPURA UTTAR PRADESH UTTARAKHAND WEST BENGAL
• District*

  Choose District
• City / Sub District / Tehsil*

  Choose City / Sub District / Tehsil

• Village / Block

  Choose Village / Block
• Pincode*

Disability Details

• Disability Due To

  Select Disability Due To Accident Congenital Diseases Hereditary Infection Medicine

• Disability Since

  Disability By Birth

  Disability Since

  Select Disability Since 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 1899 1898 1897 1896 1895 1894

  Disability Area

  • Abdomen
  • ALL FOUR LIMBS
  • ANEMIA
  • APRAXIA OF SPEECH
  • BILATERAL VOCAL CORD PARALYSIS
  • BLADDER
  • BODY HEIGHT
  • BONE DISEASE
  • BOTH EARS
  • BOTH EYE
  • Both Hand
  • BOTH LEG
  • BOTH LOWER LIMB
  • BOTH UPPER LIMB
  • BOTH UPPER LIMB AND BOTH LOWER LIMB
  • Brain
  • Chest
  • Developmental Disorder
  • DYSARTHRIA
  • Ears
  • Elbow
  • Elbow Spine
  • EPILEPSY
  • FACE
  • FINGERS
  • Foot
  • Foot Knee
  • GLOSSECTOMY
  • Hand fingers
  • HEAD
  • Heel
  • Hip
  • Knee
  • Knee Left Leg
  • Knee Right Leg
  • LARYNGECTOMY
  • Left Arm
  • Left Arm Left Leg
  • Left Arm Right Arm
  • Left Arm Right Leg
  • LEFT EAR
  • Left Eye
  • Left Eye Right Eye
  • LEFT HAND
  • Left Leg
  • Left Leg Right Leg
  • LEFT LOWER LIMB
  • LEFT UPPER Limb
  • Locomotor/OH
  • LONGITIUDINAL DEFICIENCIES
  • MAXILLOFACIAL ANOMALIES
  • Mental Illness
  • MENTAL ILLNESS (HEARING)
  • MENTAL ILLNESS (IQ)
  • MENTAL ILLNESS (LEARNING)
  • MENTAL ILLNESS (VISION)
  • Mental Retardation
  • MIND MENTAL
  • MODERATE MIND
  • Mouth
  • Neck
  • Nose
  • PROFOUND MENTAL
  • PSYCHOLOGICAL PROBLEMS
  • Right Arm
  • Right Arm Left Leg
  • Right Arm Right Leg
  • RIGHT EAR
  • Right Eye
  • RIGHT HAND
  • Right Leg
  • RIGHT LOWER LIMB
  • RIGHT UPPER LIMB
  • Shoulder
  • Spine
  • Stomach (pet)
  • Throat
  • TRANSVERSE DEFICIENCIES
  • Trunk
  • WHOLE BODY

• Do you have disability certificate? *

  Yes

  No

  Upload Disability Certificate*

  (Only jpeg, jpg, png and pdf with size 10 KB to 500 KB allowed)

• Sr. No. / Registration No. of Certificate*

  Date of Issuance of Certificate*

  Details of Issuing Authority*

  Select Issuing Authority Chief Medical Office Medical Authority

• Disability Percentage (%)

• Hospital for assessment/issue of UDID card /disability certificate

• Is your treating hospital in other state ?

  Hospital Treating State / UTs

  Choose State / UTs ANDAMAN AND NICOBAR ISLANDS ANDHRA PRADESH ARUNACHAL PRADESH ASSAM BIHAR CHANDIGARH CHHATTISGARH DADRA NAGAR HAVELI AND DAMAN AND DIU DELHI GOA GUJARAT HARYANA HIMACHAL PRADESH JAMMU AND KASHMIR JHARKHAND KARNATAKA KERALA LADAKH LAKSHADWEEP MADHYA PRADESH MAHARASHTRA MANIPUR MEGHALAYA MIZORAM NAGALAND ODISHA PUDUCHERRY PUNJAB RAJASTHAN SIKKIM TAMIL NADU TELANGANA TRIPURA UTTAR PRADESH UTTARAKHAND WEST BENGAL

  Hospital Treating District

  Choose District

• Hospital Name *

  Select Hospital

• Captcha*

  Please enter total shown in the page

  I hereby declare that what is stated above is true to the best of my knowledge *