Enable India Registration Form
WRITE IN
CAPITAL
LETTERS
File No: _____ Reg No _____ Date:_________
Employment
Computer Trg
English Trg Personality Dev Employment Trg
__________________________________________________________________
REG FOR:
Name:
Present Address:
__________________________________________________________________
__________________________________________________________________
_________________________________________________________________
Permanent Address:
__________________________________________________________________
____________________________________________________________
____________________________________________________________
Date of Birth:
________________
Marital Status: ________________
Email:
________________
Age:
_____________
Gender:_________________
Phone No: _________________________________________
Languages
Known:
_________________________________________
Disability Type:
Physically Disabled
Visually Impaired
Hearing Impaired
Mental Retardation
Mental Illness
Cerebral Palsy
Deaf-Blind
Learning Disabled
Disability since (Birth/ Age of):__________ Cause of disability* : ________________________________
*illness, genetic condition, accident, medical term
Educational Qualifications:
15+ years education
< 15 years education
** Put latest qualification first. If currently studying some course, mention word “doing” & expected year of completion
Course/Qualification**
Year
Result
Salary Expectation: ___________________ Government Job Preferred: Y
N
Job Desired: 1. ______________________________ 2. ________________________________________
Willing to relocate: Y
N
Anywhere/cities: _____________________________________________
For Official Use (CANDIDATE - DO NOT FILL)
Comments made by officer (Tick appropriate points after psychological profile)
Good attitude
Confident
Energetic
Good communication
Worldly
Motivated
Can handle stress
Emotionally mature
Independent
Good body language
Good personality
(smart)
High adaptability
Company/job ideas / current matching - _____________________________________________________
Additional Qualifications:
Telephone Operator
Computer Training
Work Experience:
Designation
Place
Year
ITI
Salary
Other (Specify)
Reference Person
Phone
Reason for Leaving Previous Job:
________________________________________________________
/Wanting to Leave Current Job
Work/Career Goals:
_________________________________________________________
Hobbies / Interests:
_________________________________________________________
Landmark of present address – (circle the closest landmark) Out of Station
North BLR
South BLR
East BLR
West BLR
Central BLR
Banaswadi
Mekhri Circle
Peenya
Yeshwantpur
Banashankari
Jaya Nagar
Koramangala
Hosur Road
Whitefield
Indira Nagar
Cantonment
Majestic
Rajaji Nagar
Vijay Nagar
Mysore Road
M G Road
J C Road
Double Road
Knowledge of Computers: Tick all that apply
Word
Excel
Internet
Folder Management
DTP
Other
Email
__________________
Communication in English: (Circle applicable points after TESTS)
Person can be understood (clarity – making sense)
Person can read (normal/Braille/large font)
Yes
Yes
No
No
Person can comprehend written or spoken
Yes
No
Person can write (normal/Braille/large font/using computers)
Yes
No
Person can spell words
Yes
No
Person can understand spelling formations
(Can hear spelt word and understand it)
Yes
No
Communication in Hindi/ Kannada/ Tamil/ Telugu/ others:
Person can speak
Yes
No
Person can read
Yes
No
Person can write
Yes
No
Background:__________________________________________________________
Relationship
Occupation
Father
Mother
Brother-_______nos
Sister - ________nos
Husband/Wife
Children________nos
Are there any other disabled members in the family?
Income/month
Yes
No
Contact
For all disabilities: Can travel by public transport
This Section is For Visually Impaired: (Tick relevant points)
Disability Description:
Totally Blind
Extent:
Light Perception
Visually Impaired
Low Vision
Colour Perception
Need Contrast
Can make out objects
Has Side Vision
Has Central Vision
Has blurred vision
Night Vision
Have Problem with Bright Light
Have Mobility
Needs cane to travel well
Mobility:
Uses cane to travel
(due to severe sight issues)
Can travel alone
Can travel only if accompanied
Can travel alone in night
Use Braille to r/w
Use normal font to r/w
(Low vision) Eyes hurt after r/w
Use audio to read
Use large font to r/w
Use magnifier to read
Reading/Writing
This Section is for Hearing Impaired: (Tick relevant points)
Di Disability Description:
Totally deaf
Partially deaf (eg:cochlear impl)
Hard of hearing
Can make out loud sounds
Can hear speech if quiet room
Can make out voice sounds
Can speak
Can make sound
Can lip read
Know sign language (ISL)
Only understands gestures
Extent:
(not distinct)
Know sign language (ASL)
This Section for Physically Disabled: (Tick relevant points)
Disability Description:
Physically disabled
Extent:
Mild (no aid)
Muscular dystrophy
Cerebral Palsy
Medium (aid used)
Severe (wheelchair)
One leg
Both legs
One arm
Both arms
Dwarf
Hunchback
Floor walker
Paraplegic
Quadriplegic
Calipers
Crutches
Artificial Limbs
Uses tricycle
Independence
Can push wheelchair on own
Uses ground cart
Uses modified vehicle
Wheelchair needs to be pushed
Need help to walk
Can stand for 8 hours
Can sit for 8 hours
Need help for eating
Need help for hygiene issues
Can speak and be understood
Jerky movement
Aids
This Section for Mental Illness/Retardation: (Tick relevant points)
Condition (MR)
Can read/write
Condition (MI):
Under constant medication
Can count
Cannot handle stress
Can understand simple commands
Need rest intervals or no contact
Tests Conducted
Profile:
________________
English:
________________
Computers: ________________
_________: ________________
_______ : __________________ _______ : __________________
Accounts : __________________ Technical: __________________
_______ : __________________ ________: __________________
Personal Development Plan: (Tick all relevant points) EXPLAINED TO PARENT ___
Know yourself
Cultivate Independent
mentality
Remove self pity
Develop boldness
Wear clean clothes
Care for external skin/hair
Reduce body odour
Reduce gestures*
(visually impaired )
Make virtual eye contact
(visually impaired)
Learn about sighted
world
Improve posture
&body language
Learn gestures for
sighted world
Travel alone
Get mobility training
Learn braille
Learn Sign
Language
Write with large font
Use audio for reading
Learn speech and
sounds
Learn lip reading
Employment
Learn about diff jobs
Learn about disabled in
diff jobs
Learn about assistive
aids & tech
Understand job you
Like
English
Improve basic spoken
Improve Written
Improve Business
Communication
Spelling /Grammar
Logical Thinking
Slow down rate of
speech
Improve Accent
Personality
Personal
grooming
Rehabilitation
General
Commn
Life Skills
Improve clarity
Cultivate Work ethics
Learn Professional
Courtesy
General Skills
Computer
Skills
Technical
Skills
Soft Skills
Analytical
Improve Worldly
knowledge
Social interaction skills
Aptitude tests
Commn & followup
Take Responsibility
Networking skills
Improve Typing -___
______________________
__________________
________________
_________________
______________________
__________________
________________
___________________
________________
Attention to detail
Team work
Learn more about _______________________________________________________
Job Suitability Details: (after counseling using videos/self)
IT - software
BPO
HR/admin
Lecturer/Teacher
Medical -___
Law - ______
Finance - _________
______________
Data entry
Machine work
Tailor
Tel operator
Skilled
Cashier
Supervisor
Electrical/Electronics
_____________
Garments
Factory Work
Helper/HK
Standing job
Unskilled
Sitting job
Repetitive job
_____________
Referred By: _____________ Phone (Person who referred): _____________Form filled by:________________
VRC reg num (if applicable): _______________________________________
Other Comments:___________________________________________________________
Professional