ENLIGHTEN SOME ONE'S WORLD BY DONATING EYES
Registration Form for Pledging Eyes
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Personal Details
Name
*
:
Father's Name
*
:
Date Of Birth
*
:
Pin Code
*
:
Mobile No.
*
:
E-mail ID
:
Blood Group.
*
:
Select Blood Group
AB+
AB-
A+
A-
B+
B-
O+
O-
Other
Form filling Date
District
*
:
Select District
Amritsar
Barnala
Bathinda
Faridkot
Fatehgarh Sahib
Fazilka
Ferozpur
Gurdaspur
Hoshiarpur
Jalandhar
Kapurthala
Ludhiana
Mansa
Malerkotla
Moga
Muktsar
Pathankot
Patiala
Rupnagar
Sangrur
SBS Nagar
SAS Nagar
Tarn Taran
Other
Address
*
:
Emergency Contact Person Details
Name
*
:
Address
*
:
Contact No.
*
:
Relation.
*
:
Select
Mother
Father
Brother
Sister
Spouse
Son
Daughter
Grand Mother
Grand Father
Grand Son
Grand Daughter
Other
Self-Declaration - Note:
(i) Organ donation is a family decision. Therefore, it is important that you discuss your decision with family members and loved ones so that it will be easier for them follow through with your wishes.
(ii) The pledger has the option to withdraw the pledge at any time during their lifetime.
