Information Collection For Special PDS Card For Physically Challenged Person

Start filling the information form in the following steps:
1. District *		2. Block/ULB *
3. Gram Panchayat *		4. Village *
5. Ward No. *		6. Locality *

Beneficiary Details
5. Name *		6. Age *
7. Gender *	Male Female	8. Relation *	Husband Father
9. Relation’s Name *

10. Disability details

10(a). Disability Type

*

10(b). Percentage of Disability

% *

10(c). Disability Certification Number

*

10(d). Certificate Date

*

11.Authorized Member to Take Ration(if any)
11(a). Name of the Authorised Member *		11(b). Relationship with the Disabled person *
i. Gram Panchayat *	*Select GP in case you deal with FPS Dealer belongs to other GP
ii. Ward No. *	*Select Ward No. in case you deal with FPS Dealer belongs to other Ward No.
12. Name of Nearest Fair Price Shop Dealer *	* Please Select the CheckBox against FPS Dealer Name