Particulars of the Outstanding Creative Adult Persons with Disabilities for National Awards (Annexure-L)
| 1. | Name of the person in Hindi & English (In BLOCK Capital letters) | |
| 2. | Residential address along with telephone no. and fax number, if any. | |
| 3. | E-mail address, if any | |
| 4. | Web-site address, if any | |
| 5. | Date of Birth/Age | |
| 6. | Nature and degree of disability (attach Disability Certificate) | |
| 7. | Occupation | |
| 8. | Monthly income | |
| 9. | Particulars of the creative work for which award is to be considered |
Signature of the applicant with date
Signature, name & designation of the recommending authority with date
NOTE:
- Three copies of the photographs clearly showing disability of recommended person with disabilities, to be enclosed with bio-data.
- Application should be supported by a Medical certificate indicating the degree of total disability.
