FORM C
[See Rule 8]

I _______________ daughter/wife of __________ aged about _______________ years of­­ ___________________________________________________________
                                   (here state the permanent address)
at present residing at ______________________________ do hereby give my consent to the termination of my pregnancy at _______________________________________
____________________________________________________________________
          (State the name of place where the pregnancy is to be terminated)
Signature
Place:
Date:
(To be filled in by guardian where the woman is a lunatic or minor)
I ______________________ son/daughter/wife of ___________________
aged about ________ years of ______________ at present residing at ___________
_________________________________________________________________
                                                        (Permanent address)
do hereby give my consent to the termination of the pregnancy of my ward who is a minor/lunatic at _____________________________________________________
                                  (place of termination of pregnancy)
Signature
Place:
Date: