Punya

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DOWNLOAD APPLICATION FORM

Patient Photo (jpg,jpeg and max 2mb

NAME AND ADDRESS OF PATIENT

PERSONAL INFORMATION

TELL US THE NAMES OF ALL MEMBERS OF THE FAMILY

First Name	Last name	Relationship to patient		Occupation

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DETAILS OF YOUR MONTHLY INCOME
Please include all earnings from jobs (after deduction of income tax), benefits and allowances including DLA etc. for ALL members of the household. Please ensure that this section is correctly completed; failure to do so will result in your application being rejected.

Source	Amount

MEDICAL INFORMATION

(haemodialysis / CAPD / kidney transplant / pre-dialysis / other (state)):

Medical Certificate (jpg,jpeg and max 2mb)

DECLARATION BY PATIENT (OR PARENT/GUARDIAN)

Signature (jpg,jpeg and max 2mb)

DECLARATION BY PANCHAYATH /CORPORATION / MUNICIPALITY

Upload Declaration Certificate From Panchayath /Corporation/municipality &nbp;(jpg,jpeg and max 2mb)

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