Disability application form

Disability application form is filled by an individual in order to get registered as disabled in the records of the government. This will help him to get the benefits prescribed for disable individuals. for more application forms

Sample disability application form

Social Security Number: _____________________________

Full Name: __________________________________________

Permanent Address: ____________________________________________________

Present Address: _______________________________________________________

Contact No.: ____________________________________

Gender: ___________________

Marital Status: _____________________

Date from when you are having disability: ____________________

The cause of the disability is: Accident / Disease / Other, Please mention _____________

Are you employed? Yes / No.

If Yes,

Name of the organization: ______________________________________

Total duration of employment (in years): ________________

Monthly Salary: __________________________

Are you presently undergoing any treatment for your disability? Yes / No.

If Yes,

Date when your treatment started: _____________________________

Name of the medical practitioner: _____________________________

Medicines you take: ________________________________________

Total duration of your treatment: ______________________________

Are you presently receiving any monetary benefits on account of your disability?

Yes / No.
If Yes,

Total amount received (per month): _________________

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