Eye Pledging Registration Form

Donation Pledge Form for the Family

In the hope that we may help others, we hereby make this anatomical gift to be effective upon our death. We would like to donate our eyes after death for the purpose of transplantation, research and education. We would further take the responsibility of information the Eye Bank of any death that we come to know and arrange to Eye Donationion.

Sl No	Name in Block Letters	Sex	Age	Relationship	Signature
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Signature of the Head of the Family

Name and Signature	Address & Phone No

Signature of the Witness

Name and Signature	Address & Phone No