Particulars of Role Model for National Award (Annexure-F)
| 1. | Name in English (in BLOCK Capital letters) and in Hindi | |
| 2. | Address along with telephone & fax number, if any. | |
| 3. | E-mail address, if any | |
| 4. | Nature and degree of Disability (Attach Disability Certificate) | |
| 5. | Indicate percentage of disability and since when | |
| 6. | Date of birth | |
| 7. | Educational qualifications | |
| 8. | Brief details/particulars of the achievements made which may be considered original and exemplar for persons with disabilities | |
| 9. | Whether any National or International award received and if so, the details thereof |
Signature of the applicant with date
Signature of the recommending authority with date
