Particulars of the Individuals for National Award (Annexure-D)
| 1 | Name in English (in BLOCK Capital letters) and Hindi | |
| 2 | Address with telephone numbers/FAX number(if any) | |
| 3 | E-mail address, if any | |
| 4 | Date of Birth/Age | |
| 5 | Sex | |
| 6 | Institution with which the individual is associated including the local and field performances and the number of persons with disabilities covered. | |
| 7 | How is the performance of the individual adjudged as outstanding | |
| 8 | Remarks including a brief life sketch of the individual. | |
| 9 | No. of years working for the persons with disabilities. | |
| 10 | Details of her/his contribution during last ten years supported by documentary evidence. | |
| 11 | Whether received any awards in the past, if so specify and furnish a brief account. | |
| 12 | Name of the Area/District/State in which outstanding work has been done for the welfare of persons with disabilities. | |
| 13 | Details of outstanding professional achievements, if any |
Signature of the applicant with date
Signature of the recommending authority with date
