Concession certificate for pationts Concession to Cancer} Thalassemia Major/ Heart (only for Heart operation)’ T.B /Lupas Valgaris Now-infectious Leprosy / Patents suffering from soverchnoderate form of Haemophilia’ AIDS patents for sretsyent a nominated ART centres / Kidney patonts only for dialysishkidney transplant operaGon Patients/ Sickle eoli Anacmia/ Aplastic Anaefnia pationts - tward Journey Form for the purpose of issue of Rail Concession to Cancor/ Thalassemia Major / Heart (only for heart operation) /' uupas Valparis/ Non-infectious Leprosy / Patients suffering from severe/moderate form clysis/kidney transplant operation/ Sickle coll Anaemia/ Aplastic Anaemia patients** to be used by Officer-in -charge of the recognized bospital by Health Department of central Government or the concemed State Government To The Station Master, This is to certify that MrVMrs/Ms._._, whose particulars are furnished below; is bonafide Cancet/ Thalassemia Major / Heart only for heart operation / T.B/Lupas Valgaris/ Non-intectious Leprosy / Patients suffering from severe/moderate form of Haemophilia’ AIDS patients for treatment at nominated: ART centres’ Kidney patients only for dialysis/kiduey transplant operation’ /Sickle cell Anuemia/ ‘Aplastic Anaemia patients ** and is required to travel fom (Station) to (station). The patient has secured admission for treatment/is travelling for periodically check uplopetation ** at + hospital/Institute/centre** Particulars of the Patient @) Age Sex Station Date Signature Officer-imcharge of the (Hospitai/institute recognized by Health Department of Central Government’ State Government/ Nominated Anti Retroviral ‘Therapy(ART) centre in case of AIDS patients) (Name of the State) Seal/Stamp of the hospital/Institute/Centre ** Strike out where not applicable. *. Indicate name of the Hospital /Institute/ (Fecognized by Health Department of Central Government ot the State Government concemed)/Nominated Centre, Note: 1. This certificate is valid for three months from the date of issue except for cancer patients which is valid for one year. 2. No alteration in this form is permitted 3. Corttfieate shotld be issued to patients only for travelling from tho station serving his place of residence tothe station serving the recognized — Hospital/Institute/centre,Oia ay Faw Rereeh wearers eemaamren AsaecRN esr Se aitear a] Beyer Aap awaURinRT BS aerate eatfndhar a ier detvoner waned Awa ge Soe A AE eam Seve A; Qt FRE sera a FET aoe altterer th donner der eAencenfRe WaT Br Aa gy a are Rect mseas WAT savtetiner aavecafair Far va sister a Beer dager aaa geo Vitter eonfcter Be Ber Aetvenir waa Area we sare Ar BME ewer Sahat By tot A araaeR ay Frere aincaie sttesr & doves da uAuacnftee vai YM aera at a art any Rena w far other wee ar eer oe were A RTE RMT, ART AAT TT ever AF say sien gare swehor Se ort & fee ore ae sonia Fran aren te Avance fawar far ae far mer Barer at Ae Aoweaaeh cor Sieh ativtesr & fauyers Varga anise geo Tai aT Realftrchar & a dene wane aaah we soaw A fare war telvise a eet Pa sere Rais qieonic aiteterr 2 eevee der caMavsceniten weer g ha GE athe gee (eter) Yo (Ree) wee oat aT BI set Me seaaeiaien A sqrt Se afer & far Sonate atastisteer — & fae sar we wer EH Whar fart areca Psnar GANT AFT WIC STETSTAY eemevege ttt are a artes wareet Bez) (ea a a) srerararereoratieg ot Fever av oet a] at BY Be HE El prereset ct rom ress Ree er viet ae) APG Hee HT ae ate: 4. ae vaoaT oe wet fr argrer S cha sider fae AA sue dar, ax Aftret at vse ati fe ae we af & fae fait are eh 2. sa wet A Ratt vane ap oRacer fee ort St sept ag 8) 3. ag wens afta at dae sae Rare ere & Tee SF ATT weg sre FR ar wey & few net fee awe