EYE DONATION PLEDGE FORM

Please fill out the following form

I hereby pledge to donate my eyes posthumously to CHIRANJEEVI EYE & BLOOD BANK RESEARCH & DEVELOPMENT CENTRE. I would like my eyes to be used for visually challenged persons to enable them to gain sight.

DETAILS OF THE DONOR

First Name

Last Name

Date of Birth

Phone

Email

Sex:

Male

Female

Other

Blood Group

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

DETAILS OF FAMILY RELATIVES

Name

Phone

Email

Relation With Donor

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

I declare that the info I’ve provided is accurate & complete

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Donor's Signature

Thanks for agreeing to become a donor! You are doing a great service to humanity.