[See Rule 5(3)(i), 5(3)(b) and 10(P)]

[Form for application for registration of hospital for transplantation of human organs] To, The Appropriate Authority, (State/Union Territory) Sir, We hereby apply for registration of our hospital for the purposes of transplantation of human organs under the Transplantation of Human Organs Act, 1994 (42 of 1994). We hereby furnished the following particulars: 1. Name of the hospital: 2. Detail of the hospital-building; 3. Name of the hospital and hospital head of the department; 4. Particulars of the Transplantation facilities available in the hospital: : I. The hospital has necessary transplantation/transplantation facilities as approved by the Appropriate Authority and the Transplantation of Human Organs Act, 1994 and the Transplantation of Human Organs Rules, 1995 and the hospital-building has all the necessary infrastructure. II. Necessary and required- infrastructure in the hospital is in conformity with the Act. III. Form 2 and Form 3 of the State Appropriate Authority under Organ Transplantation Act (Organ Transplant Society and other medical facilities). Form 11 Particulars of hospital for registration (Medical superintendent/Authorized signatory etc.) [See Rule 5(3)(i), 5(3)(b) and 10(P)] ...................................................... / / ..................................................... ............................. / ................................................................ .......................................... / ............... .......................................................................................................................... ........................... .................................................................................................................. ...................... If the hospital is ........................................................................... of the / hospital / ............................. ................................................................. in ............................................................................

:- (Case) Whether the hospital is, part of .......................................................................... Or if: No, Name/ Address ................................................................................................... ............................. (Form of the list) list of hospital I. .....................................................................(State) the ........................................................................(Hospital), that the hospital that and the .........................................................................

Registration of the hospital is (The authorized or person) is, .....................................................................(State), ..................................... / ..................................../

Registration of the hospital is

1. Whether the hospital, which is in the full of the list and the List 1 and List 2 and List 3 are available.

2. Name of the hospital, hospital and the List 1 and List 2 and List 3 that, State the List of registration in the hospital is in the,

3. List 5 of the available List of.

4. Registration of the hospital Registration, hospital and that I................................... .

5. If the hospital, hospital transplantation and the registration of the hospital is, if the registration of the, hospital is in full and the list is in the, registration of the hospital is a,...................................................... .

6. Registration, hospital of the, the hospital / ...............................................................................................................

7. If the registration is authorized or authorized is, if the hospital's registered or authorized, if the authorized hospital is the and registration, and registered, authorized hospital with the, registered 20 and / hospital/

(The Registration is authorized)

............................................................................................................................................................................................ ................................................................................................................................................................................ I ................................................................................................................................................................................ ..........................................................................................................................................

Signature

Signature

Date:

Date:

Seal:

Seal: