Medical Certificate for the Blind

                                Certified that I, Dr. …………………………………………………………

Registration No………………………………………….. have this……………………………

Day of …………………………………….200.....               examined the candidate whose particulars are given below.

1.                     Name of candidate

2.                     Father ‘s name

3.                         Sex

4.                         Approximate

5.                         Identification mark

6.                         Extend of residual vision, If any R.E.

                                                                L.E.

7.                    Onset   of  blindness ( please state whether  blindness is from birth or acquired later if it has been caused afterwards the age and cause of blindness may be indicated ) For the purpose of these scholarship the blind are those who suffer from either of the following.

a)             Total absence of sight

               b)              Visual acuity not exceeding 6/60 of20/200

                                                (snellen )  in the better eye with correcting  

                                                lence

c)                    Limitation of the field of vision sub  standing Lence.

8.            Please State clearly whether the candidate is blind for the purpose of scholarship.

 Signature of application                                                      ( Signature of Opthalogist )

Place                                                                                                                 Designation

Date                                                                                                                 Office Stamp

                                                                                                               Address