AFFIDAVIT – CUM – UNDERTAKING

I Dr/ Shri/Smt./Kum__________________________________________________

Son/Daughter/wife of________________________________________________

Aged_______________Years resident of _________________________________

Owner/Proprietor/Institution Head Of Genetic Counselling Center/Genetic Laboratory/Genetic

Clinic/Ultrasound Clinic/Imaging Center/Combination I here of do here by declare and state on solemn
affiliation as under.

I, say that I undertake to abide by the provisions of the Pre-Conception and Natal-Diagnostic
Technique’s (prohibition of sex Selection) Act 2003 and the rules made there under.

I, further say and undertake that the Genetic Center/Genetic Laboratory/Genetic

Clinic/Ultrasound Clinic /Imaging Center combination there of as the case may be shall not conduct any
test of procedures, by what-so-ever name called, for selection of “Sex” before or after conception or for
detection of sex of fetus except for diseases specified in section 4(2) nor shall the sex of fetus will be
disclosed to anybody.

I also undertake to explain the said act and rules to all employees of the Genetic Center/Genetic
Laboratory/Genetic Clinic/Ultrasound Clinic /Imaging Center in respect of which registration is sought
and to ensure that Act and Rules are fully compiled with. I also undertake to display prominently at the
Genetic Center/Genetic Laboratory/Genetic Clinic/Ultrasound Clinic /Imaging Center combination there
of as the case may be, a notice that we do not conduct any technique , test or procedure , etc by
whatever name called for detection of sex of fetus or for selection of sex before or after conception.

This affidavit is made for submitting the same to the Appropriate Authority along with an
application of Registration of Genetic Center/Genetic Laboratory/Genetic Clinic/Ultrasound Clinic
/Imaging Center or combination thereof as the case may be . The above contents are true and correct to
the best of my knowledge and belief.

Place :

Date:

Identified by me: ( _________________________________ )

Name , Designation and Signature

Of the person authorized to sign on

behalf of the organization to be registered.

Before me.