Akhil Bhartiya Terapanth Yuvak Parishad

Eye Donation Registration Form

Donner Details

Full Name *

Gender *
Male Female

DOB *

Mobile Number *

OTP *

Profile Image *

Email Id

Address *

Location Details

State*

Parishad Name

City *

Personal Details

Father's/Husband's Name*

Mother's Name

Pledge detail

Blood Group

Emergency Contact Details

Name*

Mobile Number*

Relation*

Members to be Notified

Same as emergency contact

Name *

Mobile Number *

Relation *

Name of Individual/NGO/Institution Who Motivated You To Pledge

Individual*

Name/NGO

Note: (i) Eye Donation is a family decision. Therefore, it is important that you discuss your decision with family members and loved ones so that it will be easier for them follow through with your wishes. (ii) The pledger has the option to withdraw the pledge at any time during their lifetime.

Full Name	Jitender
Gender	Male
Date of Birth	1995-03-01
Mobile Number	7053400328
Address Details	H No X-19/5, Street No 8, Brahmpuri, Ghonda, North East, Delhi