This affidavit should be done on 100 Rs Stamp paper and notary

before me

AFFIDAVIT (ART LEVEL –I CLINIC ) ( IUI )

I Dr./Mr./Mrs. _______________________________ Son Of/Daughter Of /Wife Of

____________________Aged ___ _____Resident of ____________________________
Owner /Director/Proprietor of (Centre Name And Address)
_______________________________________________________________________________________________________

Do Hereby Solemnly Affirm On Oath That I have read and

understood The Assisted Reproductive Technology (Regulation) ACT, 2021
& Rules 2022.

1. I have consented to do Procedures related to ART Level I Clinic

( IUI ) (like collection of husband semen sample, processing of
semen sample, insertion of processed semen sample in patients uterine
cavity etc.) at. (centre name and address) ___________________

2. I shall not conduct any test or procedure by whatever name called

for selection of “sex” before or after conception or for detection of
sex of foetus.

3. I display prominently a notice that I shall not conduct any

technique, test or procedure etc ,by whatever name called for
detection of sex of foetus or for selection of sex before or after
conception.

4. I also undertake to explain the said Act and Rules to all employees of
ART Clinic in respect of which registration is sought and to ensure
that Act and Rules are fully complied with.
5. The contents in para 1 to 4 Are True & Correct To The Best Of My
Knowledge And If Found False,I May Be Liable For Punishment
Under Section 199,200,193(2) Of Indian Penal Code .
And the affidavit solemnly affirmed at _____ (place) on ___________
(date)

Date :-

Sign & Name & stamp of

Owner /Director/Proprietor
This affidavit should be done on 100 Rs Stamp paper and notary
before me

AFFIDAVIT (ART LEVEL –I CLINIC ) ( IUI )

I Dr./Mr./Mrs. _______________________________ Son Of/Daughter Of /Wife Of

____________________Aged ___ _____Resident of ____________________________
Owner /Director/Proprietor of (Centre Name And Address)
_______________________________________________________________________________________________________

Do Hereby Solemnly Affirm On Oath That I have read and

understood The Assisted Reproductive Technology (Regulation) ACT, 2021
& Rules 2022.

1. I have consented to do Procedures related to ART Level I Clinic

( IUI ) (like collection of husband semen sample, processing of
semen sample, insertion of processed semen sample in patients uterine
cavity etc.) at. (centre name and address) ___________________

2. I shall not conduct any test or procedure by whatever name called

for selection of “sex” before or after conception or for detection of
sex of foetus.

3. I display prominently a notice that I shall not conduct any

technique, test or procedure etc ,by whatever name called for
detection of sex of foetus or for selection of sex before or after
conception.

4. I also undertake to explain the said Act and Rules to all employees of
ART Clinic in respect of which registration is sought and to ensure
that Act and Rules are fully complied with.
5. The contents in para 1 to 4 Are True & Correct To The Best Of My
Knowledge And If Found False,I May Be Liable For Punishment
Under Section 199,200,193(2) Of Indian Penal Code .
And the affidavit solemnly affirmed at _____ (place) on ___________
(date)

Date :-

Sign & Name & stamp of

Owner /Director/Proprietor