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    Organ Donation: Form for DadhichiDehDanSamiti

    Uploaded by

    suresh t
    Consent form for Organ donation

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Organ Donation: Form for DadhichiDehDanSamiti

    Uploaded by

    suresh t
    6 views16 pages
    Consent form for Organ donation

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

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    Consent form for Organ donation

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    6 views16 pages

    Organ Donation: Form for DadhichiDehDanSamiti

    Uploaded by

    suresh t
    Consent form for Organ donation

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 16

    <br>

    Badhichi SBA Ban Sana 1997


    JSR 2
    W-99, Greater Kailash-I, New Delhi -110048 W-99, et hAyT-1, T3 fa-110048
    Reg. No.: 32411 of 1998 PAN no.. AAATD3388A, 80G no.: AAATD3388AF20219
    www.dehdan.org [email protected] dadhichidehdansamíti t dadhíchidehdan
    9811106331, 9811066405, 9811598598, 9582883432, 9818345704

    Pledge for Body-Organ Donation after death

    Dear Sir
    Inthe Cause of Humanity, Iresolve to Signature /aH
    donate, after death, my eyes/ all
    transplantable organs/full body.
    1. Personal Details /fT SIHbIt

    Name

    Date of Birth: Sex: Blood Group:


    fiI
    Father's/Husband's Name:

    Mother's Name:

    Address

    Pin Code:
    f ais
    E-mail

    Occupation

    Mobile Phone-Res: Phone-Off:


    t-614it
    2. Other Useful information (Education, Designation, field of Interest etc):

    3. Iwish to donate (please tick)

    () Only Eyes / A a
    (ü) AlTransplantable Organs

    (iii) Whole Body


    <br>

    4. Two Witnesses (One should be from close family):

    1 2
    HIH Name
    YT Address

    HqY Relationship
    HGET Mobile
    SA Email
    1T Signature

    Please appoint an Executor to communicate with the Samiti, when time comes for it
    :
    5.

    Name |A

    Address /YI

    6. We shall be obliged for your kind donation preferably by Cheque or in Cash of Rs. 200 or more in the
    name of 'Dadhichi Deh Dan Samiti' to cover expenses for your 1-Card, Certificate, Willand of registration
    of the donation. The donation to the Samitienjoys the benefit of Section 80G of the Income Tax Act.

    7. Motivator's Name and Address

    VERIFICATION /HAIYT
    hereby verify that the above information is true to my knowledge. I request
    Dadhichi Deh Dan Samiti to take necessary action in accordance with my pledge.

    Date /fih Signature / IT

    For Office use only /haT ATaera à yi àT


    (i) Date /faHG
    Form received on/ 5ÍH YTT
    Form acknowledgment/ 5j4 Ya Icard / ytg
    Certificate/ YHU 4A Will /arya
    g
    (i) Receipt Number and Date /7 f HI 4 3n fIA
    (ii) Donor Number / HYEIGI T 34AHH
    <br>

    NECESSARY INSTRUCTIONS /3[yyci Ho

    1. Please complete your form and send it with your one photograph and donation if any at the following
    address:

    General Secretary
    Dadhichi Deh Dan Samiti
    u
    W-99, Greater Kailash-1 gary-99, N-1,
    New Delhi 110048 T frit 110048

    2 The law requires that your pledge has two witnesses. One of the witnesses must be from close family
    member (Spouse, Parent, Brother, Sister or major child).

    3
    Upon the death of a donor, his/her family has to inform the Samiti at any of the following numbers
    9811106331, 9811066405, 9811598598, 9582883432, 9818345704.
    The Samiti then coordinates with the family and makes all arrangements of the donation.
    The documents required are (i) the Certificate/ ldentity Card the donor issued by the samiti
    of

    (iüi)
    Certificate from the treating doctor about the cause of death or the death summary from the hospital
    (iii) Voter card /Aadhar card or other proof of identity of the donor.
    If the donor was not registered, his close family member can give a certificate conveying the resolution

    of the family to so donate.

    9811598598, 9582883432, 9818345704.

    4. Your local contacts in Delhi – NCR

    Zones / a Name / TA Mobile / IgT


    North Delhi Shri G.P. Tayal 9810133551

    North-East Delhi ShriYogendra Agarwal 9212764515

    East Delhi Smt. Gunjan Gupta 7290014818

    West Delhi Shri Jagmohan Saluja 9560264264

    South Delhi Shri Deepak Goyal 9810172766

    Central Delhi Shri Manoj Jindal 9811659740

    Ghaziabad and Noida Shri Avinash Chandra 7982194324

    Faridabad Shri Rajiv Goel 8527937970

    Buland shahar and Greater Noida Shri Rakesh Kumar 8130777066


    <br>

    www.dehdan.org

    . 8130777066

    GEGIoI! 3jIG|OI!
    <br>

    GEGIOl! 3jolGIo|!

    GGol!
    <br>

    3jOJGIOl!

    GGTT Hfih- yoY (Brain Stem Death) a- R


    <br>

    1.

    2.

    3.

    st t.t. e 9810133551
    t 4 fuG 9811659740

    9212764515 st stqMRT as-7982194324


    siH TI 7290014818 sft VIq 8527937970

    8130777066

    1997 I9HY

    W-99,
    T
    e:9811598598,
    GAN-1, fReit-110048
    9811106331,
    9811066405, 9818345704
    [email protected] • www.dehdan.org
    <br>

    ,3 gar GT, 2 freGIH T 6 AH GE ufrui o


    EGI,872
    <br>

    REGYCLE
    1DONOR
    CAN SAVE LIVES
    8
    YOURSEEF
    BECOME AN

    ORGAN DONER
    <br>

    EYE DONATION - Let some one


    see the beauty through your eyes
    <br>

    -
    Yg foIy HAft faHTfNF (Bi-monthly)
    <br>

    1997 H 3UIN
    25 uruia

    W-99, R
    ocT, y-I, el-110048
    bT:98111 06331, 98110 66405, 98115 98598, 98183 45704
    M [email protected] E www.dehdan.org
    dadhichidehdansamiti G dadhichidehdan

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