Note:

posting in

be paid by
Postage will
addressee. For
Singapore only

National_Organ.indd 3
21056_Form (pink)2.ai

(c) Non-Muslims
11/17/05
12:24:49 PM

1. This objection to organ removal only applies to -

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

Singapore 169608
PERMIT NO. 01589
Singapore 169608

c/o Singapore General Hospital

BUSINESS REPLY SERVICE

National Organ Transplant Unit

(b) Persons aged between 21 to below 60 years; and
c/o Singapore General Hospital

contact the Officer-in-Charge at the above address or call Tel No. 63214390.
(a) Singapore Citizens and Singapore Permanent Residents;
NATIONAL ORGAN TRANSPLANT UNIT

4. If you do not receive an acknowledgement to your objection to organ removal within 3 weeks, please
3. Please forward the completed form together with a photocopy of your NRIC to the following address:
21056_Form (pink)1.ai 11/17/05 12:23:51 PM
National Organ Transplant Unit

Please fold here

Please glue here

This form may take you 5 minutes to fill in

HUMAN ORGAN TRANSPLANT ACT (CHAPTER 131A) For Official Use Only
OBJECTION TO ORGAN REMOVAL UNDER SECTION 9(1)
(Please complete all particulars in BLOCK LETTERS)

FULL NAME (as in NRIC): DATE OF BIRTH:

NRIC NO.: - SEX: Male Female RACE: Chinese Indian Others

(please specify)

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

Citizen Resident

HOME ADDRESS: POSTAL CODE:

I hereby object to the removal of the following organ(s) for transplantation upon my death (please tick “ ” one or more as applicable):
“ ”
Please glue here

Kidney Liver Heart Cornea

SIGNATURE: DATE:

NAME OF WITNESS (as in NRIC): NRIC NO.:

ADDRESS: POSTAL CODE:

SIGNATURE: DATE:
MD 136
10/2004
Please glue here
5/3/07 1:46:39 PM