No. S.
12011/2/94-MS
O.P. Nigam Chief Controller of Account
FORM
- 1
(See rule 3)
I, ...................................................,
aged
................... S/o, D/o, W/o ............................ resident of
....................... ......................... hereby authorise
to remove for therapeutic purposes / consent to donate my
organ, namely.
.................................................................
......…………………………......................................
(1)
Mr. / Mrs. .................................................
S/o, D/o, W/o, Mr. .............................………..........
aged ...................... resident of
..........................
happens to be my near relative as defined in clause (2)
of section
2 of the Act.
(Or)
(2)
Mr./Mrs. ......................................................
S/o, D/o, W/o, Mr. ................................…..........
aged ................................. .................resident of
.........................................................
.........................towards when I possess special affection,
attachments, or for any special reason (to be specified).
I certify that the above authority/consent has been given
by me out my own free will without pressure, inducement, influence
or allurement and that the purposes of the above
authority/donation and of all possible complications,
side-effects, consequences and options have been explained to me
giving this authority or consent or both.
Signature of the Donor
|
