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Social Contribution : Eye Donation

PLEDGE YOUR EYES

EYE DONATION PLEDGE FORM

I, hereby declare my solemn intention to donate my eyes to PCMC ADITYA JYOT after my demise that this wish be put into effect by inviting a remove both eyes upon death for therapeutic transplantation or medical research and education.

Dear Donor, Please fill the following information to register.
DONOR NAME : *
Age : *
sex : *
address : *
state : *
country : *
pin no : *
telephone : *
email : *
WITNESS NAME : *
Relation With donor : *
Witness Address : *
Witness Telephone No : *
Witness Email : *
Verification Code :	Enter the verification code which is shown in the box.

Fields marked with * are mandatory.

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