Rail Travel Concession Form for the Blind

(Rule 101, Serial No.24)
CONCESSION CERTIFICATE

Paste passport size photograph Duly signed and stamped by the Issuing Doctor For completely Blind persons to be used by a Regd. Medical Practitioner/Government Doctor/Heads of the Institutions for the Blind recognized by Ministry of Welfare/Govt. of India or Social Welfare Deptt. of the concerned State Government
This is to certify that Km./ Shri./ Smt. .................................................., whose particulars are furnished below, is a bonafide "Orthopaedically handicapped/Paraplegic person/patient and IS COMPLETELY BLIND.
Particulars of the Blind patient :
  1. Address : _________________________________________________________________
  2. Father's/ Husband's Name : ___________________________________________________
  3. Age : ____________________________________________________________________
  4. Sex : _____________________________________________________________________
  5. Nature of handicap (To be written by Doctor whether the disability is temporary or permanent) : _________________________________________________________________________
  6. Causes of loss of functional capacity : _____________________________________________
  7. Signature or Thumb Impression of Blind person: _____________________________________
    __________________________________________________________________________
Place : _________
Date : __________

Signature of Govt. Doctor

____________________________________
Clear Seal of Govt. Hospital/ Clinic 		______________________________________
Seal Containing full name and Regd. No. of Doctor
* Strike out where not applicable Note:
  1. The Certificate should be issued only to those COMPLETELY BLIND PERSONS. The photo must be signed and stamped by the certificate issuing Doctor/person in such a way that the signature and stamp appears partly on the photo and partly on the certificate.
  2. The certificate is valid for five years from the date of issue. After expiry of the period of validity of the certificate, the person is required to obtain a fresh certificate. A Photostat copy of the certificate is accepted for the purpose of grant of concession. The original certificate will have to be produced for inspection at the time of purchase of concessional ticket and during the journey, if demanded.
  3. No alteration in the form is permitted.