EYE PLEDGE FORM

Please send us______________________nos. of Eye Donor Cards. Our address is:

Name, Age and Signature of Adult Family Members who wish to pledge eye for donation as family commitment are given below:

S.No

Name

Age

Sex

Signature

1.

2.

3.

4.

5.

To be filled in by two witness (neighbours or friends) if you have no living relatives

Name

Signature

1. Witness 1

2. Witness 2

1. Cards will be sent by ordinary  post 2. Allow two weeks for delivery 3. Preserve your cards. Duplicate will cost you Rs. 50.00