CONCESSION CERTIFICATE FOR MENTALLY RETARDED

Paste passport size

Photograph duly signed

And stamped by issuing

Government Doctor

Form for the purpose of

grant of rail concession to

MENALLY RETARDED

persons to be used by

Identification marks:1.
2.

This is to Certify that Km./Shri/ Smt----------------------------------------------------------------------------------
details furnished below is a bonafide Mentally Retarded person and CAN NOT TRAVEL WITHOUT AN ESCORT.

Particulars of the Mentally Retarded Person:-

(a) Address--------------------------------------------------------------------------------------------------------------                      --------------------------------------------------------------------------------------------------------------                      --------------------------------------------------------------------------------------------------------------

(b) Father’s / Husband’s Name---------------------------------------------------------------------------------------

(c) Age-------------------------------------------------------------------------------------------------------------------

(d) Signature or left hand thumb impression

    of Mentally Retarded Person: -----------------------------------------------

Place:-----------------

Date:------------------

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(Signature of the Psychiatrist)

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