Full Name (required) E-mail Phone(WhatsApp number if possible) (required) Guardian/Representative/Organization Name Partner Organization (required) APH: Belgaum BPA: Ahmedabad SNEH : Nagda INALI Foundation: Pune Dextroware Devices: Chennai VYO: Rajkot Neomotion: Chennai VIPO : Vadodara Indent Trestle Labs Country (required) Select Country India State (required) Select State City (required) Select City Select Assistive Device/Service Daisy Player Smart Phone Tricycle Wheelchair Hearing Aid Sewing machine Beauty Parlour Kit Saarthi (Smart Cane) Kibo App Subsidized Products: (* Subsidized by Voice of SAP) Kibo XS device for visually-impaired Mouseware (Wearable head device) Neofly (customized wheelchair) Neobolt (Motorized wheelchair) Power Wheelchair(Indent) Robotic Arm(Inali) Birth Date (required) Aadhar Card Number Did you receive any Assistive Device in past? (required) Yes No Which Assistive Device and how many years before you received it? How this assistive device will help you? (required) Tell us about you and your family? (required) Family income per year (required) 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) BPA - Ahmedabad GATORBHAI HIMMATLAL PATEL (BIDAJ) ORTHOPAEDIC & GENERAL HOSPITAL LIONESS KARNAVATI HOSTEL FOR BLIND WOMEN & BPA GUEST HOUSE KUTCH COMPREHENSIVE REHABILITATION CENTRE (KCRC) MSM-NAAZ SAMMILIT PATH SHALA & RESIDENTIAL CENTRE SHRI R.M. PARIKH RESOURCE CENTRE (SUMERU CENTRE) PALDI KASHIBHAI LALITABEN BHADRABEN & JAGDISHBHAI PATEL “SAMARPAN SANKUL SAVINAY CENTRE FOR INCLUSIVE EDUCATION - BAVLA KHUSHIYO NU SARNAMU DEESA DR. JIT MEHTA BALSHALA TRUST PRAYAS DAY CARE CENTRE JODHPUR, RAJASHTHAN BLIND PEOPLE’S ASSOCIATION NADIAD BRANCH Ashirvad Viklang Trust New VIP Road, Vadodara New Delhi Varanasi, UP Jabalpur, MP Hyderabad, Telangana Nagda, MP Belgaum, Karnataka Haridwar, Uttarakhand Home Delivery Download Kibo App Delivery Address Attach Aadhar card (required) Attach Medical certificate/UDID (required) I confirm that information submitted is accurate.
