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a full size photo showing

nature of handicap(visiting
card size),attested by HM
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schl seal HM
 CONVEYANCE ALLOWANCE FORMAT FOR THE DISABLED!

Ref: Finance (pay cell) Department G.o. Ms.No .667,Dated ; 27..6.1989

Finance (pay cell) Department G.o. Ms.No . 445, Dated : 31.8.1998
Finance (pay cell) Department G.o. Ms.No .391, Dated :07.10.2010

1. Name of the Candidate :

2. Designation :
3. Place of work :
4. Father / Husband :
5. Sex :
6. Date of birth :
7. Details of the disability :
8. Percentage of disability :
9. Place of residence :
10. Permanent Address :

11. Distance from office to :

residence
12. Signature of the applicant :
13. Medical authorization
14. signature of the medical officer :
With full registration No and seal

15. signatureof the head of the Institution:

DETAILS OF PAY
1. Basic salary
2. Dearness Allowance
3. Medical Allowance
4. House Rent Allowance
5. Special Allowance

DECLARATION
I certify that Who is working as
in our Institution has not availedconveyance allowance so far.
HM
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schl!seal HM

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schl!seal HM

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MEDICAL CERTIFICATE FOR PHYSICALLY HANDICAPPED

This is to certify that…………………………………..whose

particulars are furnished below is a bonafieted orthopaedically handicapped.

Particulars of the Orthopaedically handicapped person:

1)Address :

2)Father’s Name :

3)Age :

4)Sex :

5)Nature of Handicap : Permanent/Temporary

6)Percentage & cause of

loss of functional capacity :

7)Signature of Ortho.Handicap person:

Place : Signature of the Dr. with seal

Date:

photo showing
nature of handicap
attested by Dr Hospital round seal
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5* CONVEYANCE ALLOWANCE FORMAT FOR THE
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