Full Name (required)
E-mail (required)
Phone(WhatsApp number if possible) (required)
Birth Date (required)
Disability Type
(required)
Select Disability Type
Amputee
Hearing Impaired
Locomoter Disability
Mental Illness
Visually Impaired
Multiple Disabilities
Explain how Disability Limits your Functioning (required)
Guardian/Representative/Organization Name
Partner Organization
(required)
Select Partner Organization
34 Assam Rifles Srinagar
APH: Belgaum
Bharat VIkas (Patna)
Bethany Society: Meghalaya
Blind People Association
Care Educational Trust: Lucknow
Caritas Centre for Deafblind
Creativiti Council
Devnar School for the Blind
Deva International Society (Varanasi)
Dextroware Devices: Chennai
EUPHELITY PVT LTD
Flexmotiv Technologies Pvt. Ltd.
H VISION INDIA PRIVATE LIMITED
Kalyanam Karoti Mathura
Lions Blind Girls School, Vadodara
NAB - Nashik, Maharashtra
NAB : Pune, Maharashtra
NAB: Bharuch
NAB: Goa
Nav Bharat Jagriti Kendra : Patna Branch
NFBM, Pune
Office of the Chief Education Officer, Leh Ladakh
Oneceptual Technologies
Orbit Research
Paralympic Sports Association Kolhapur, Maharashtra
Rotary Club - Geetanjli Kolkata
Sabarmati Samruddhi Seva Sangh, Gandhinagar
Sahayatha Healthcare
Sathiyameh Jayam Charitable Trust - Chennai
She Hope Society for Women Entrepreneurs
Shri Navchetan Andhjan Mandal Divyang Vidhya Vihar, Bhuj
Shri Unique Viklang Charitable Trust, Rajkot
Signable Communications
Siddh Divyang Foundation, Pune
Sneh (Nagda, MP)
Sunbots Innovation
Sunbots innovation for App
SYSS
Torchit
TRESTLE LABS For Kibo App
TRESTLE LABS For Kibo XS Device
VOSAP Jodhpur Chapter
VOSAP Pune Chapter
WeHear
Shri V.H. Gandhi Deaf & Dumb School
Shri Chhaganlal Shamji Virani Bahera-Munga Shala Trust - Rajkot
Country
(required)
Select Country
State (required)
Select State
City (required)
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District
Select District
Heavily Subsidized
Tricycle
Beauty Parlour Kit
Daisy Player
Flexmo Premium Elbow Crutch
CiCare
Flexmo Premium Underarm Crutch
Flexmo silent walker
Smarton Smartglasses (Age 14 and above)
Signable- ISL Interpreter Service (Any age)
CP Walker
Kibo App (1 Year Subscription)
Kibo App (3 Year Subscription)
Mouseware (Wearable head device)
Kibo XS Device with Perpetual License
Kibo XS Device with Annual License
Sahayatha 100
Sahayatha 200
Vision Wallet
Orbit Braille Reader(Any age 20 Cell)
Jyoti AI Glasses
Callipers / Braces
Orbit Reader 20 Plus
Orbit Reader Q20
Orbit Reader 40
Orbit Reader Q40
Heavily Subsidized ( Prosthetic / Orthotics )
AK Prostheses
BK Prostheses
Air Splint
Cervical Collar
Dennis Brown Splint
Knee Cap
Knee Cap with Hinge
O. A. Brace
L.S. Belt
Molded ACL Caliper without shoes
Molded ACL Caliper with shoes
Walking Stick
Partially Subsidized
Neofly (customized wheelchair)
Combo (Neofly+Neobolt)
Electric Tricycle
VGO Wheelchair Attachment
Govt ID Number (UDID/Pan Card/Voter ID Card) (required)
Select ID Type
UDID
Pan Card
Voter ID Card
Other
UDID Number (required)
Pan Card Number (required)
Voter ID Card Number (required)
Govt ID Number (required)
Please Select Subsidy For Device (required)
Select
1500 Rupees Payable
100% Free of cost
Primary Use of Assistive Device
(required)
Select Primary Usage
Education
Employment / Self Employment
Safety / Mobility
Communication
Explain the Usage Purpose in Detail
(required)
Tell us about you and your family?
(required)
Family income per year
(required)
Select Family Income Per Year
Less Than Rs 1.5 LAC
Rs 1.5 LAC To Rs 3 LAC
Rs 3 LAC To Rs 5 LAC
Above Rs 5 LAC
Delivery Center
(required)
Select A Delivery Center
Delivery Address
Please Select Applicant Type (required)
Select Applicant Type
Renewal
New