ENLIGHTEN SOME ONE'S WORLD BY DONATING EYES
Registration Form for Pledging Eyes
Personal Details
Name
*
:
Father's Name
*
:
Date Of Birth
*
:
Age
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
*
:
Pin Code
*
:
Emergency Contact Person Details
Name
*
:
Address
*
:
Contact No.
*
:
Eye Bank Details
State
*
:
Select State
District
*
:
Select District
Name of Eye Bank & Conatct No
*
:
Select Eye Bank
I Want to pledge my eyes for eye donation after my death. My family members also support my decision.
This is to certify that the above said information given by me is accurate and I know that my name will be displayed in the list of Eye Donors on the official website if I have chosen to pledge my eyes.
