Please glue here

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):
For Official Use Only

(please specify)
Singapore 169608
c/o Singapore General Hospital

Others
ORGAN DONOR REGISTRY

POSTAL CODE:

POSTAL CODE:
Please glue here

Please glue here

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


Indian

NRIC NO.:
PERMIT NO. 01589
BUSINESS REPLY SERVICE

Chinese
DATE OF BIRTH:

DATE:

DATE:
Singapore only

RACE:
posting in

✓
TEL NO.:
addressee. For
be paid by

Heart


Organ Donor Registry

Female
Postage will

!"#$%&'()*
 !"#$%& “✓”

Please fold here

Male
HUMAN ORGAN TRANSPLANT ACT (CHAPTER 131A)

S'pore Permanent
SEX:
Note:

(Please complete all particulars in BLOCK LETTERS)

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

Resident
(c) Non-Muslims
who have submitted their objections earlier to organ removal.

Liver
-


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

3. Please forward the completed form together with a photocopy of your NRIC to the following address:
Organ Donor Registry

Citizen
S'pore
c/o Singapore General Hospital

NAME OF WITNESS (as in NRIC):

Singapore 169608
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.

FULL NAME (as in NRIC):

CITIZENSHIP STATUS:

!"#$%&

HOME ADDRESS:

SIGNATURE:

SIGNATURE:
Kidney

ADDRESS:
NRIC NO.:



MD 137
5/2004