T he applicant has submitted the following documents

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T he applicant has submitted the following documents as proof of residence Nature of Document Date of issue Details of authority issuing signature 5. Signature and seal of the Medical Authority Name and seal of Member Name and seal of Member Name and seal of the Chairperson Signature/Thumb impression of the person in whose favour disability certificate is issued
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Page 28 of 35 PROFORMA-III-C CERTIFICATE REGARDING PHYSICAL LIMITATION IN AN EXAMINE TO WRITE This is to certify that, I have examined Mr/Ms/Mrs ………………………. (name of the candidate with disability), a person with ……………… (nature and percentage of disability as mentioned in the certificate of disability), S/o/D/o …………………….. a resident of ………………………… (Village /District/State) and to state that he / she has physical limitation which hampers his/her writing capabilities owing to his / her disability. Signature Chief Medical Officer / Civil Surgeon/ Medical Superintendent of a Government health care institution Name & Designation Name of Government Hospital / health Care Centre with Seal Place: Date: Note: Certificate should be given by a specialist of the relevant stream / disability (eg. Visual impairment Ophthalmologist, Locomotor disability Prthopaedic specialist / PMR).
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Page 29 of 35 PROFORMA-IV LETTER OF UNDERTAKING FOR USING SCRIBE NOTE: Candidates Visually Impaired(VI)/candidates whose writing speed is affected by Cerebral Palsy /muscular dystrophy/ candidates with loco motor disability (one arm)/Intellectual disability (Autism, specific learning disability and mental illness) are eligible for Scribe. PARTICULARS OF SCRIBE PROPOSED TO BE ENGAGED BY THE CANDIDATE 1. Name of the Candidate ........................................................ 2. Roll No…………………………………………………………. 3. Name of Center…………………………………………. 4. Qualification of Candidate ……………………………………. 5. Disability Type ………………………………………………… 6. Name of the ............................................................... 7. Date of Birth of the Scribe … ................................................ 8. Father’s Name of the Scribe ................................................. 9. Address of the Scribe: (a) Permanent Address ........................................................... ............................................................................................ (b) Present Address ................................................................ ............................................................................................ 10. Educational Qualification of the Scribe ................................. .................................................................................................. .................................................................................................. 11. Relationship, if any, of the Scribe to the Candidate…… .............. 12. DECLARATION: i) We hereby declare that the particulars furnished above are true and correct to the best of our knowledge and belief. We have read/ been read out the instructions of the CBSE regarding conduct of the candidates assisted by Scribe/Scribes at this examination and here by undertake to abide by them. ii) We do hereby undertake that the qualification of scribe is mentioned correctly and the qualification of the scribe is one step below qualification of candidate. In case, subsequently it is found qualification of scribe is not as declared by the candidate, I (the candidate) shall forfeit my right to the post and claims relating thereto. iii) We declare that the Scribe herself / himself is not a candidate in this examination. We understand that in case it is found otherwise the candidature of both of us will be rejected.
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