Withdrawal Of Objection Form

NRIC NO.:

DATE:

DATE:

POSTAL CODE:

Cornea




✓


Heart

MD 137 5/2004

SIGNATURE:

ADDRESS:

NAME OF WITNESS (as in NRIC):




SIGNATURE:




Liver Kidney

!"#$%&'()*
 !"#$%& “✓”

!"#$%&


HOME ADDRESS:




TEL NO.: S'pore Permanent Resident S'pore Citizen CITIZENSHIP STATUS:

I hereby withdraw my objection to the removal of the following organ(s) upon my death for transplantation (please tick “✓” one or more as applicable):

POSTAL CODE:

Others (please specify) Indian Chinese RACE: Female Male SEX: -

HUMAN ORGAN TRANSPLANT ACT (CHAPTER 131A)

4. If you do not receive an acknowledgement to your withdrawal of objection to organ removal within 3 weeks, please contact the Officer-in-Charge at the above address or call Tel No. 63214390.

NRIC NO.:

be paid by Postage will

3. Please forward the completed form together with a photocopy of your NRIC to the following address: Organ Donor Registry c/o Singapore General Hospital Singapore 169608

DATE OF BIRTH:

Organ Donor Registry

2. This form shall be invalid if it is not duly completed.

FULL NAME (as in NRIC):

addressee. For posting in Singapore only 1. This withdrawal of objection to organ removal only applies to (a) Singapore Citizens and Singapore Permanent Residents; (b) Persons aged between 21 to below 60 years; and (c) Non-Muslims who have submitted their objections earlier to organ removal.

(Please complete all particulars in BLOCK LETTERS)

BUSINESS REPLY SERVICE PERMIT NO. 01589 Note:

WITHDRAWAL OF OBJECTION TO ORGAN REMOVAL UNDER SECTION 11(1)

Please glue here

ORGAN DONOR REGISTRY c/o Singapore General Hospital Singapore 169608 Please fold here

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For Official Use Only

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