Certificate by the Authorisation Committee of Hospital

(If Hospital Authorisation committee is not available then the Authorisation Committee of the district/State) where the transplantation has to take place (To be issued on the letter head) [See rules 16 and 23] Th is is to certify th at as per application in form-10 for transplantation of _____________________(Name of Organ/tissue) from living donor, other than near relative/ swap donation cases/ all foreigner under the Transplantation of Human Organs Act, 1994 (42 of 1994) submitted on..................................by the donor and recipient, whose details and photographs are given below, along with their identifications and verification documents, the case was considered after the personal interview of donor and recipient (if medically fit to be interviewed) and their relatives as applicable by the Authorisation Committee in the meeting held on ...dated................................. Details of Recipient Details of Donor Name.............................................. Name :................................................. Age................................................. Age..................................................... Sex................................................ Sex..................................................... Father / Husband Name .............. Father / Husband name.................... Adddress: Address: Hospital Reg. No........................... Hospital Reg. No. Relation of donor with Recipient.................................................................................. Recipient Donor (Photo of recipient and donor must be signed and stamped across the photo after affixing) Permission is granted, as to the best of knowledge of the members of the committee, donation is out of love and affection and there is no financial transaction between recipient and donor and there is no pressure on / coercion of the donor. Permission is withheld pending submission of the following documents.............................................. Permission is not granted for the following reasons (Member) Name and Designation (Member) Health Secretary Or Nominee Date and place............... (Member ) (Member ) (Member) Name and Designation Name and Designation Name and Designation (Member ) ( Sign of Chairman with stamp ) DHS or Nominee Name and Designation Name and Designation * In case of SWAP transplants, details are to be annexed