Registration - Beneficiary

Male Female 3rd Gender
Yes No
CALLIPERS
LEGS
LIMBS
HEARING AID
CANE
WALKERS
WHEELCHAIR
COMMODE CHAIR
TRICYCLE
STOOLS STIMULATOR CANE
CATHETERS
URINE BAGS
Right Left Both
Right Left Both
Right Left Both
Right Left Both
Right Left Both
Right Left Both

If you choose WHEELCHAIR/ COMMODE CHAIR/ TRICYCLE

If you choose STOOL STIMULATOR/ CATHETERS / URINE BAG

YES NO

Proof of Identity

Reference