Victorian Consolidated Regulations

Infertility Treatment Regulations 1997 - SCHEDULE 3

Regulation 19 APPLICATION FOR INFORMATION FROM THE CENTRAL REGISTER To the
Infertility Treatment Authority: Full name of applicant Address Telephone
number Full name of person born as a result of a donor treatment procedure
Relationship of applicant to person born as a result of a donor treatment
procedure

*Identifying/*Non-identifying information required from central register
Signature of applicant Date

*delete if not required ---------------