Concession Certificate
(for Outward Journey)
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Forms for the purpose of issue of Rail concession to Hemophilia Patients to be used by Officer-In-charge of the recognized Hospital

This is to certify that Mr./Ms. _________________, whose particulars are furnished below, is suffering from severe/moderate form of Hemophilia and is required to travel from (station) to _______________ (station) for treatment/periodical check-up at _____________________ Hospital.
Particulars of the Hemophilia Patient
(a) Age (b) Sex
Place _______________ ________________________________________
Date _______________ (Signature, Name & stamp of officer-in-charge
Of recognized hospital issuing this certificate)
Seal/stamp of the recognised hospital
Notes:-
1. This certificate is to be issued by Officer in-charge of the recognized hospital where the above named patient is to be treated. This should be issued to only those patients who are to treated for severe/moderate form of Hemophilia.
2. This certificate is valid for three months from the date of issue.
3. No alteration in the certificate is permitted.
4. This certificate is to be issued for outward journey from the station serving the patients place of residence to the station serving the hospital.

Concession Certificate
(for Return Journey)
**********************************
Forms for the purpose of issue of Rail concession to Hemophilia Patients to be used by Officer-In-charge of the recognized Hospital

This is to certify that Mr./Ms. _________________, whose particulars are furnished below, is suffering from severe/moderate form of Hemophilia and is required to travel from (station) to _______________ (station) after treatment/periodical check-up at _____________________ Hospital.
Particulars of the Hemophilia Patient
(a) Age (b) Sex
Place _______________ ________________________________________
Date _______________ (Signature, Name & stamp of officer-in-charge
Of recognized hospital issuing this certificate)
Seal/stamp of the recognised hospital
Notes:-
5. This certificate is to be issued by Officer in-charge of the recognized hospital where the above named patient is to be treated. This should be issued to only those patients who are to treated for severe/moderate form of Hemophilia.
6. This certificate is valid for three months from the date of issue.
7. No alteration in the certificate is permitted.
8. This certificate is to be issued for outward journey from the station serving the patients place of residence to the station serving the hospital.