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Personal Information

First Name*

Middle Name

Last Name*

First Name (Nepali)*

Middle Name (Nepali)

Last Name (Nepali)*

Gender*

DOB*

Citizenship No*

Citizenship issued district*

Blood Group

Blood RH

Father's Name in Nepali*

Mother's Name in Nepali

Spouse Name in Nepali

Father's Name in English*

Mother's Name in English

Spouse Name in English

Contact Information

Email

Mobile Number*

Address

Province*

District*

Municipality*

Ward No.*

Street Address*

Elderly Details

Staying in Care Center*

Care Center Name*

Care Center Address*

Caretaker's Name*

Caretaker's Address*

Catetaker's Contact No*

Relationship with Caretaker*

Suffering from Disease?*

Name of Disease*

Name of Medicine

Disability Details

Disability Type (As per Nepal Government) *

Category of Disability by inability*

Reason of disability*

Describe the damage in parts of body, structure or system*

Effect on daily life due to the damage*

Do you require to use any external aid ?*

Type of aid*

Are you using the aid currently*

Name of the aid*

Activities without aid

Activities with help

Name Trainings (If you have taken any)

Educational Qualification*

Occupation*

Occupation Name*

Attachments

Photo of applicant*

Photo of Citizenship*

Proof of disability (Photographs and documents related to disability)

I want to apply for

Personal Information

Contact Information

Address

Elderly Details

Disability Details

Attachments

News and Notices

Reports

eGov Services

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