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www.karunadu.gov.in/dmekarnataka or
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GOVERNMENT OF KARNATAKA
No:PMSSY/SSH/ 28 /2011-12
Ph:0802670
5883,
Dated: 26/12/2011
( DD towards application fees shall be submitted in the name of Special Officer, PMSSY Super Speciality Hospital
Bangalore)
Note: Incomplete application and application without DD are liable to be rejected. Service experience and other
details may be obtained through the website.
Sd/Special Officer
PMSSY Super Speciality Hospital
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NOTE:
1. This condition is progressive/non-progressive/likely to improve/not likely to improve.*
2. Re-assessment is not recommended/is recommended after a period of ............................ months/year *
*Strike out which is not
applicable.
(Recent attested
Photograph
showing the
disability affixed
here)
Sd/Arthopaedic /
Eye /ENT /Psychiatrist
Member, Medical
Board
Sd/Senior Specialist
Member, Medical
Board
Sd/Chairperson District
Surgon District
Hospital
Countersigned by the
Medical Superintendent CMO / Head of
Hospital (with Seal)
Signature/Thumb impression
Of the disabled person.
24
GOVERNMENT OF KARNATAKA
DEPARTMENT OF SAINIK WELFARE AND RESETTLEMENT
Office of the Deputy Director
Department of Sainik Welfare & Resettlement
(Karnataka)
No.------------------------------------
Date:-------------------------
CERTIFICATE
This is to certify that Shri/Smt/Kum---------------------------is an applicant for --------------is the
spouse /son/daughter of No----------Rank--------Name------------------------------of Army / Navy / Air Force, who is an Ex-serviceman according to the definition laid down by the Ministery
of Defence, Government of India. He served from ---------------to -------------------The Ex-Serviceman had declared his home town in Karnataka at the time of entry into service as
per records & hence eligible to avail reserved seats under Ex-Serviceman quota. His permanent home
address at the time of entry into service was as under:
Home address before joining service:
--------------------------------------------------------------------------------------------Place:
Date:
CERTIFICATE
This is to certify that Shri/Smt/Kum---------------------------is an applicant for --------in Karnataka is the
spouse /son/daughter of No----------Rank--------Name--------------------------- who died /disabled while in
service according to the certificate issued by Defense Authority. He died / disabled on -------------------Home address of the individual at the time of joining Defense Service as per the records is:
--------------------------------------------------------------------------------------------Place:
Date:
25
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