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, Mr. ..................................... 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
