Eye Donation Pledge Form

Gender :
Date of Birth: Calendar
 (Enter date in dd/mm/yyyy format)
S/o W/o D/o:
Father/Husband Name :
Contact No :
Address :
District :
State :
Pin Code :
Email Id:
(Detail of Next of kin who will inform to Eye Bank for eye donation after death of pledge taker)
1)Next Kin Relation :
Name :
Contact No :
E-mail :
2)Next Kin Relation :
Name :
Contact No :
E-mail :
Insert Text as in Image 
I have filled up this form voluntarily and in my full consciousness. I have understood about eye donation process and advised my next of kin to immediately inform the Eye Bank GMCH on my death so that the process of eye donation can be carried out. The information furnished above is correct to the best of my knowledge.