Eye Donor Registration

Male Female Transgender

Name Date of Birth

Email Mobile No

Address

State City

Pincode Blood Group

Upload Photo (JPG/PNG Only) (Optional) Upload ID Proof (JPG/PNG Only) (Optional)

Family Member #1

Name of a Family Member Relationship with the donor

Contact No. of Family Member Email of Family Member

Family Member #2 (optional)

Name of a Family Member Relationship with the donor

Contact No. of Family Member Email of Family Member

Family Member #3 (optional)

Name of a Family Member Relationship with the donor

Contact No. of Family Member Email of Family Member

Family Member #4 (optional)

Name of a Family Member Relationship with the donor

Contact No. of Family Member Email of Family Member

By clicking submit you agree that all the information provided by you is correct. "I have willingly given the consent to donate my eyes after my death to any eye bank in india through this online form knowing that my name will be published on the website as a part of eye donation campaign and I will get only E-EYE DONOR (PLEDGE) CARD."

Reg No:

Date of Issue:

Name:

Address:

Contact:

Date of Birth:

Blood Group: