Department of Empowerment of Persons with Disabilities,

Ministry of Social Justice and Empowerment, Government of India

Acknowledgement / Resident Copy

Person with Disability Registration

Enrolment No: 2703/00000/2201/0921342 Enrolment Date: 16/01/2022

PERSONAL DETAILS

Gajanan Pandurang
Name of Applicant आवे दक का नाम गजानन पांडुरं ग वै कार
Vaidyakar

Applicant Father's Name Pandurang Vaidyakar आवे दक के िपता का नाम पांडुरं ग वै कार

Applicant Mother's Name Droupadabai आवे दक के माता का नाम दौपदाबाई

Date of Birth 04/09/1990 Age 31 Year(s)

Gender Male E-Mail Id ---------

Mark of Identification --------- Category Obc

Mobile Number --------- Blood Group ---------

Marital Status ---------

Relation with PwD

---------
(Person with Disability)
Name of Guardian / Contact No. of Guardian /
Caretaker / Attendant / --------- Caretaker / Attendant / ---------
Related Related

Address of Correspondence

Address Chikhali, Muktainagar, Muktainagar (edlabad), Jalgaon, Maharashtra - 425306

पता िचखली, Muktainagar, Muktainagar (edlabad), Jalgaon, Maharashtra - 425306

Nature of Document for Aadhaar Card

Address Proof

Permanent Address

Address Chikhali, Muktainagar, Muktainagar (edlabad), Jalgaon, Maharashtra - 425306

पता िचखली, Muktainagar, Muktainagar (edlabad), Jalgaon, Maharashtra - 425306

Educational Details

Highest Qualification Middle/higher Primary

DISABILITY DETAILS

Do you have disability certificate? Yes Disability Type Locomotor Disability

Sr. No. / Registration
Disability certificate uploaded? Yes 364900
No. of Certificate
 Details of Issuing
Date of Issuance of Certificate 10/01/2017 Chief Medical Office
Authority
Disability Percentage 40%
Disability Area Left Leg,Right Leg Disability Since
Pension Card Number ---------
Hospital Treating Disability --------- Disability Due To ---------
Hospital Name ---------

EMPLOYMENT DETAILS

Employed or Unemployed --------- Occupation ---------

BPL / APL ---------
Personal Income (Annual) ---------

IDENTITY DETAILS

Identity Proof --------- TIN (NPR) ---------

Aadhaar No. 645399984895

ASSESSMENT

Disability Type Sub Type Affected Part Diagnosis Remark

Right foot crush injury
Locomotor Disability ---------- Right lower limb Nil
with ankle arthritis

VIEW RECOMMENDATION

Disability Disability Permanent / Reassessment Reassessment Reassessment

Disability Remark
Percent Condition Temporary Require Review Year Review Month
Locomotor 41 (Forty
---------- ---------- ---------- ---------- ---------- Nil
Disability One)

This is computer generated receipt and does not require any signature.