Name of the PwD *

Email ID *

Contact Number *

Alternate Contact Number

Date of Birth *

Choose your option Male Female Other Gender *

Father Name *

Father Occupation

Contact No

Mother Name *

Mother Occupation

Contact No

Choose your option OC BC SC ST Caste *

Choose your option Married Unmarried Marital Status *

Choose your option Visually Impaired Speech & Hearing Impaired Locomotor Disability Cerebral Palsy Mentally Disability Other Disability *

Choose your option Blind One eye blind Pin Hole Vision Low Vision Night Blindness One ear hearing impairment Two ear hearing impairment Speech impairment Speech & hearing impairment Person with one leg disability Person with two leg disability Person with one hand disability Person with two hands disability Spinal Problem Dwarfism Other Disability Description *

Percentage of Disability *

Sadarem No *

Aadhaar No *

Address *

State *

District *

Pin Code

Choose your option USSC SSC Intermediate Degree PG Education Qualification *

Group/Trade

Percentage *

Choose your option DDU GKY PMKVY RYK Other None Have you attended any govt training program *

Please provide details if you have any health disorders / health issues