FORM 1(C) [To be completed by the prospective spousal donor]. (Refer rule 3) | |||
My full name is .............................................And this is my photograph | |||
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My permanent home address is ...................................................................................................... .................................................................Tel:................................. My present home address is ...................................................................................................... ..................................................................Tel:................................ Date of birth............................(day/month/year) • Ration/consumer Card number and Date of issue & place .......................(Photocopy attached) and/or • Voter’s I-Card number, date of issue, Assembly Constituency ..................................... (Photocopy attached) and/or • Passport number and country of issue .............................................(Photocopy attached) and/or • Driving Licence number, Date of issue, licensing authority ........................................... (Photocopy attached) and/or • PAN.............................................................. and/or • Other proof of identity and address ................................... • Details of last three years income and vocation of donor....................................... I hereby authorize removal for therapeutic purposes/consent to donate my ................ (state which organ) to my relative (specify son / daughter / father / mother / brother / sister), whose name is ........... ..........................and who was born on .......................... (day / month / year) and whose particulars are as follows: | |||
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• Ration/consumer Card number and Date of issue & place .......................(Photocopy attached) and/or • Voter’s I-Card number, date of issue, Assembly Constituency ..................................... (Photocopy attached) and/or • Passport number and country of issue .............................................(Photocopy attached) and/or • Driving Licence number, Date of issue, licensing authority ........................................ (Photocopy attached) and/or • PAN.............................................................. and/or • Other proof of identity and address ........................................... I solemnly affirm and declare that:- Sections 2, 9, and 19 of the transplantation of Human Organs Act, 1994 have been explained to me and I confirm that: -
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Signature of the prospective donor | Date | ||
Note : To be sworn before Notary Public, who while attesting shall ensure that the person / persons swearing the affidavit(s) signs (s) on the Notary Register, as well. • √Wherever applicable. |