21JStatement by sampler—Form 4

#### 21J Statement by sampler—Form 4 After taking a bodily sample from a donor, the sampler must: (a) complete a statement in accordance with Form 4 in Schedule 1; and (b) affix the photograph of the donor referred to in paragraph 21F(1)(b) to the statement; and (c) sign his or her name partly on the photograph and partly on the statement in a way that, if the photograph were later removed from the statement, the removal would be evident from inspection of the statement.