Government of Pakistan
Ministry of Human Rights
(The Council on Rights of Persons with Disabilities)
******
Date: Reg. No.
APPLICATION FOR DISABILITY CERTIFICATE
Name: ____F/Name M/Name Guardian Name:
Marital Status Married / Unmarried/Divorced/Widow/Widower Spouse Name
Date of Birth CNIC No.
Type of Disability: ____________________________Nature of functional disability________________________
Cause of Disability Age disability identified at ____________________
Landline Mobile/WhatsApp___________ Email_________________________
Domicile______________________ Present Address
Permanent Address
I solemnly declare that above mentioned information is correct and,
prior to this, I never obtained my Disability Certificate from
NCRDP, PCRDP’s. In case of wrong information, CRPD would be
in its right to initiate an action against me as per Law / Rules and
Policy.
SWO (CRPD) Signature of the Applicant/Guardian
Recommendations of the Medical Assessment Board
Applicant is declared:
Disabled/Not Disabled Disability Type _____________
Fit to work (As per disability) / not fit to work Severity of Impairment_________________
Referred to NOT FIT for DRIVING
Chairman
(Orthopedic Surgeon)
NIRM, Islamabad
Member Member Member Member
DD NCRDP ENT/Eye Specialist Audiologist-DGSE Job Placement Officer-DGSE
Other Members, if any:
Government of Pakistan
Ministry of Human Rights
(The Council on Rights of Persons with Disabilities)
******
Part-II (To be filled in case of successful Application)
Details of any Assistive Wheelchair / Hearing aid / Mother / Father / Brother / Sister /
device being used: Communication Device / Wife
Caretaker:
Screen Readers / Husband /others ______________
Others: ____
No education / Enrolled / Completed
Education: education Completed Years of Education: _____________
Qualification
Mainstream school / Special Education Institute Govt. Private Welfare Trust
Enrolled in: School / Home-based School / Other type:
Nutritional
Institute Name:
needs:
Speech Therapy/ Assistive Device/ Govt Job / Pension / Savings /
Current source
Specific needs Counseling / Others ____________ Rental Income / Dependent /
of Income:
Private Company Job
Name &
Details of
Address of
work in case
employer, in
of self-
case of an
employed:
employee
Yes No If unemployed,
Are you how long are
seeking a job you out of
work?
Details of any skill or Training you are Computer and digital skills / Electrical / Mechanical / Electronics /
seeking: Tailoring / Beautician / Arts and Crafts / Driving/Business
Monthly Misc./general
educational and disability
health costs: related costs:
Estimated recurrent cost Total monthly
of Assistive Technology, cost of care of
if any the PWD:
<30000 - <30000
30000-75000 Total income of - 30000-75000
Income of PWD, who is
75000-125000 the PWD’s - 75000-125000
sole earner in the family
125000-200000 Family: - 125000-200000
200000 < - 200000<
<30000 Age, gender,
30000-75000 CNIC and
Income of PWD, living in
75000-125000 relation of 2nd
a joint family
125000-200000 disability in the
200000 < family,if any
Nature of
Type of Disability of 2nd Functional
PWD in the family Disability of 2nd
PWD
Age, gender, CNIC and Disability
relation of 3rd disability in Certificate No
the family,if any of 2nd Disability
Additional Information
Government hospital,
Other chronic medical Nature of usual
private clinic/hospital,
ailments of Applicant, if healthcare
Free dispensaries,
any and name of provider for
Hakim, Traditional
healthcare provider disability care
Healers, Homeopaths
No Yes Partially For Hearing Aid/ wheel chair
For Financial Support
Do the household Reason for getting
For job
members financially Disability
For Education
depend on the Applicant Certificate:
For Healthcare
Other ________
- From family/friends
Details of regular - BISP
support received from - Sehat Sahulat Card
any of the following
- Pak Bait ul Maal
sources
- Trusts / NGOs
Others ____________
- Financial
- Medical Care
- Residential Care
Most Urgent Support you - Shelter
need: - Educational
(select multiple if - Asssistive Technology
options, if needed) - Rehabilitative care
- Occupational
- Legal rights protection
- Others
