रे ल या ा सु वधा हे तु आवेदन प
Concession Certificate
(Appendix 1/36, Rule No. 101 Sr. No. 25)
Paste Passport
size Photograph Form for the purpose of grant of rail concession to
duly signed and Orthopedically Handicapped / Paraplegic persons
stamped by the / patients to be used by the Government Doctor.
issuing
This is to certify that Km/Shri/Sri/Smt. ........................................................ whose particulars are
furnished below, is a bonafide Orthopedically Handicapped/Paraplegic person/patient and Cannot
Travel without the assistance of an Escort.
Particular of the Orthopedically Handicapped /Paraplegic Person / Patient :
a) Address : ....................................................................................................................................
b) Father's/ Husband's Name : ………………………………………………………………………………………………………
c) Age : ……………………………………………………… d) Sex : …………………………………………………
Nature of Handicap : ( To be written by Doctor)
e)
Whether the disability is Temporary or Permanent) ………………………………………………………………….
f) Causes of loss of functional capacity : ……………………………………………………………………………………….
Signature of Thumb impression of Orthopedically
handicapped/Paraplegic person/ Patient : (not
g)
necessary for those whose both hands are missing
or non-functional) ……………………………………………………………………………………………………………………..
Place:..................................................
........................................................
Date :................................................... (Signature of Government Doctor)
............................................................. ........................................................
Clear Seal of Government Seal Containing full name and
Hospital / Clinic Regn. No of the Doctor
* Strike out where not applicable.
Note :
1- The certificate should be issued only to those orthopedically Handicapped/ Paraplegic
persons/patients WHO CANNOT TRAVEL WITHOUT THE ASSISTANCE OF AN ESCORT. The
photo must be signed and stamped in such a way that Doctor's signature and stamp appears
party on the photo and partly on the certificate.
2- In the case of temporary disability. the certificate will be valid for five years from the date of
issue. In the case of permanent disability, the certificate will remain valid for (1) five years, in
case of persons up to the age of 25 years.(2) ten years, in case of persons in the age group of
26 to 35 years and (3) in the case of persons above the age of 35 years, the certificate will
remain valid for whole life of the concerned person. After expiry of the period of validity of
the certificate, the person is required to obtain a fress certificate. A Photostat copy of this
certificate is accepted for the perpose of grant of concession. The original certificate will
have to he produced for inspection at the time of purchase of concessioal ticket and during
the journey if demanded.
3- No alternation in the form is permitted.
