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