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Name Father/Husband/Wife
Date of Birth Age Sex Present Address
Permanent Residential Address
Profession Ph. No.

I do hereby pledge my mortal body to the department on Anatomy, S.C.B/V.S.S Medical college. To be utilized for academic research and related purpose without any prejudice or pre-condition. I declare that in case of brain death, body will be handed over at the disposal of the S.C.B/V.S.S Medical College for proper utilization of my body. I understand that the places will not , in any way affect my 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.

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