Zone:* Select Zone East Zone West Zone South Zone North Zone Central Zone

Name of NGO/Organization (if any):

Name of PwDs Candidate:*

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Gender:* Select Gender Male Female Prefer not to say Other

Date of Birth:*

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Type of Disability:* Select Disability Type Locomotor Disability Visual Impairment Hearing Impairment Hard of Hearing Intellectual Disability Low Vision Leprosy Cured Persons Dwarfism Mental Illness Autism Spectrum Disorder Cerebral Palsy Muscular Dystrophy Specific Learning Disabilities Multiple Sclerosis Speech and Language Disability Thalassemia Hemophilia Sickle Cell Disease Multiple Disabilities including Deaf Blindness Acid Attack Victims Parkinson's Disease

Disability Percentage:* Select Percentage 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Educational Qualification:* Select Qualification No formal education Primary School Secondary School Higher Secondary Diploma Bachelor's Degree Master's Degree Other

If Other Qualification, Then Specify:

Parent/Guardian Name:*

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Skill Category Interested In (Only one):* Select Skill Category Basket Making / Cane Technology Character Design Cleaning Service Crochet Dental Technician Electronic Assembly Engineering Design CAD Fashion and Design Hand Knitting Jewelry Landscape Gardening Hairdressing Manicure Massage Pâtisserie and Confectionery Cake Decoration Photography (Studio) Publishing (Desktop) Wall Tiling Welding Painting and Decorating Property Management

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