Pledge

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All fields are mandatory

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EYE DONATION

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Finish

Select Gender

Date of Birth

Name

Email

Mobile No

Date of Death

Address

State

City

Pincode

Blood Group

Upload Photo (JPG/PNG)

Upload ID Proof (JPG/PNG)

Step 2: Family Member #1

Name of Family Member

Relationship with the donor

Contact No. of Family Member

Email of Family Member

Step 3: Family Member #2

Name of Family Member

Relationship with the donor

Contact No. of Family Member

Email of Family Member

Step 4: Family Member #3

Name of Family Member

Relationship with the donor

Contact No. of Family Member

Email of Family Member

Step 5: Family Member #4

Name of 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."