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To be self attested across the affixed photograph
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To be self attested across the affixed photograph
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Photograph of the Donor
(Self-attested)
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Photograph of the Recipient
(Self-attested)
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| Whereas I ................................................ S / o, D / o, W /o, Shri/Smt. ......................................... aged ................................. residing at ......................................................................... have been advised by my doctor ................................... that I am suffering form ..................................................... and may be benefited by transplantation of........................................................ into my body.
And Whereas I .........................................S / o, D / o, W / o, Shri / Smt. ................................................. aged ........................................... residing at ....................................................... by the following reason (s): -
(a) by virtue of being a near relative i.e. …………………….
(b) by reason of affection / attachment / other special reason as explained below:- ........................................................................................
...............................................................................................
I would therefore like to donate my (name of the organ) ........................to Shri / Smt. ..................................................
We .......................................and ........................................
(Donor) (Recipient)
hereby apply to Authorisation Committee for permission for such transplantation to be carried out.
We solemnly affirm that the above decision has been taken without any undue pressure, inducement, influence or allurement and that all possible consequences and options of organ transplantation have been explained to us.
Instructions for the applications:-
| 1. Form 10 must be submitted along with the completed Form 1(A), or Form 1(B) or Form 1 (C) as may be applicable. |
| 2. The applicable Form i.e. From1(A) or Form 1(B) or Form 1(C), as the case may be, should be accompanied with all documents mentioned in the applicable form and all relevant queries set out in the applicable form must be adequately answered. |
| 3. Completed Form 3 to be submitted along with the laboratory report. |
| 4. The doctor’s advice recommending transplantation must be enclosed with the application. |
| 5. In addition to above, in case the proposed transplant is between unrelated persons, appropriate evidence of vocation and income of the donor as well as the recipient for the last three years must be enclosed with this application. It is clarified that the evidence of income does not necessarily mean the proof of income-tax returns, keeping in view that the applicant(s) in a given case may not be filing income-tax returns. |
| 6. The application shall be accepted for consideration by the Authorisation Committee only if it is complete in all respects and any omission of the documents or the information required in the forms mentioned above, shall render the application incomplete. |
| 7. As per the Supreme Court’s judgement dt. 31-3-2005, the approval/No Objection Certificate from the concerned State / Union Territory Government or Authorisation Committees is mandatory from the domicile State / Union Territory of donor as well as recipient. It is understood that final approval for transplantation should be granted by the Authorisation Committee / Registered Medical Practitioner i.e. Incharge of transplant center (as the case may be) where transplantation should be done. |
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We have read and understood the above instructions.
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Signature of the Prospective Donor
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Signature of the Prospective Recipient
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| Date .................. |
Date ..................
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| Place .................. |
Place ..................
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