Pledge Your Eyes Eye Donor (Pledge) Registration Form Name * Blood Group * SelectA+A-B+B-AB+AB-O+O-A1+A1-A2+A2-A1B+A1B-A2B+A2B-Bombay Blood GroupDon’t Know Email * Mobile * State * SelectAndra PradeshArunachalPradeshAssamBiharChhattisgarhGoaGujaratHaryanaHimachalPradeshJammu and KashmirJharkhandKarnatakaKeralaMadyaPradeshMaharashtraManipurMeghalayaMizoramNagalandOrissaPunjabRajasthanSikkimTamil NaduTripuraUttaranchalUttar PradeshWest BengalAndaman and Nicobar IslandsChandigarhDadar and Nagar HaveliDaman and DiuDelhiLakshadeepPondicherry City * Address * PinCode * Education * Select10th Pass12th PassGraduationPost Graduationother Occupation * Date of Birth * Date12345678910111213141516171819202122232425262728293031 Month010203040506070809101112 Year19251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016 Gender * SelectMaleFemale I hereby agree that all the information provided by me is correct. “I have willingly given the consent to donate my eyes after my death to any eye bank in india through this online form knowing that my name will be published on the website as a part of eye donation campaign and I will get only E-EYE DONOR (PLEDGE) CARD.”