Ministry of Social Justice and Empowerment (MSJE)

Pwd Details

Legal Guardian
Details

Bank
details

Attachments

Registered Organigation

Payment
Details

Payment
Verification

Name of PwD *:

Address of PwD

House No. * :

Street Name :

Landmark * :

State * :

District * :

City *:

Pin code *:

Land Line Number :

Mobile No. *:

Email address of PwD *:

Father’s Name/ Husband’s Name *:

Date of Birth of PwD *:

Gender *:

Marital Status *:

Other Status *:

Educational Qualification *:

Other Educational Qualification *:

Disability*:

Other Disability:

Disability Percentage:

Name of Legal Guardian * :

Mobile No. of Legal Guardian * :

Name of course * :

Other Course Name * :

Name of the University/Institute/college * :

Address of the University/ Institute/college * :

Name of Department * :

Name of HOD * :

HOD Contact Number :

Duration of course (number of months)* :

Pattern of course* :

Other Course* :

Bank details

Name of the Account Holder * :

Bank account no. * :

Bank Name * :

Other Bank Name * :

Branch Name * :

Branch City * :

IFSC code * :

Attachments

All the attachment should be pdf format except Passport Size Photograph of PwD(jpg,png,jpeg) and Size upto 5MB or less

Disability Certificate * :

Birth Certificate * :

Address Proof * :

Passport size Photograph of PwD
(jpg,jpeg,png file only)* :

Admission records of the College, Institute or RO (for the course being undertaken) * :

ID proof of parent or guardian * :

Undertaking by the parents or the guardians that the PwD will attend minimum 50 % of the classes and provide a document which proves at least 50% attendance of the PwD to obtain transportation benefit * :

Document/certificate from the Institution mentioning maximum time duration allowed to PwD for completing the course * :

Document/certificate from the Institution allowing the beneficiary to continue the course in case the course period exceeds the maximum duration allowed* :

Please upload Black and white documents unless you are asked to upload colour documents

ABOUT REGISTERED ORGANIZATION (RO)

Name of referring RO (if any) :

Year of registration of RO with The National Trust :

Date of expiry of registration of RO with The National Trust :

Payment

Amount (INR)* :

Choose payment mode * :

Receipt NO. / Transaction ID * :

Get Receipt NO. / Transaction ID

Please fill all * Marked mandatory fields

Gyan Prabha Application Form for Enrolment of PwD

Address of PwD