APPLICATION FORM (PLEDGE FORM) FOR WHOLE BODY DONATION NAMEFATHERHUSBANDWIFE

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APPLICATION FORM (PLEDGE FORM) FOR WHOLE BODY DONATION

NAME...................................................FATHER/HUSBAND/WIFE.....................................

DATE OF BIRTH...................................AGE...............................SEX.................................

PRESENT ADDRESS...........................................................................................................

PERMANENT RESIDENTIAL ADDRESS..................................................................................

PROFESSION.................................................CONTACT PH NOS............................................

I do hereby pledge my mortal body to the department of Anatomy, S.C.B./V.S.S.Medical College,

Cuttack/Burla to be utilised for academic, research and related purposes without any prejudice or

precondition. I declare that in case of my brain death, body will be handed over at the disposal of the S.C.B.,/V.S.S.Medical College for proper utilisation of my body. I understand that the pledges will not, in any way affect any legal claim.

I further declare that this pledge has been made voluntarily with good health and full consciousness and not under any pressure. I do hereby undertake the responsibility to inform about the pledge to the jurisdictional police station and also my next of kin/legal heirs about this pledge for smooth execution of the process.

Date _________Place________

Witness

(Two passport photographs to be submitted) Full signature of donor/Executants

__________________________________________________________________________________

Declaration by Next of Keen/ Legal heirs

I/we do hereby agree to honour the pledge signed by..........................................................................

Son/daughter/husband/wife/others of .................................................................and also handover

His/her dead body after brain death along with the original Death Declaration Certificate.

Sl.No. Name in Full (Capital letter) Relation with the Donor Full Signature

Witness

Sl No. Name with Address (Capital letter) Signature in Full

Date ___________place _____________

(Photocopy of Photo identity card/address proof of the Donor and next of keen are to be enclosed) The application form is to be executed in a stamp paper preferably by a Notary.

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