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

Sex:
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DETAILS OF FAMILY RELATIVES

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