Full Name
Father's Name
D.O.B
Your Age (enter only if don't Know D.O.B)
Please tick as applicable: Heart Lungs Kidneys Liver Pancreas
Any Other Orgen
(Following tissues can also be donated after brain stem deathas well as cardiac death) Corneas/Eye Balls Skin Bones Heart Valves Blood Vessels
Any Other Orgen
Blood Group if known
Mobile Number
Emergency Number
Email
Address:
Upload Signature (200 KB) Upload ID (<1 MB)
(Note: In case of online registration of pledge, one copy of the pledge will be retained by pledger, one by the institution where pledge is made and a hard copy signed by pledger and two witnesses shall be sent to the nodal networking organisation.)
(Details of Witness 1)
Name
S/O, D/O, W/O
Age
Mobile Number
Email
Address
(Details of Witness 2)
Name
S/O, D/O, W/O
Age
Mobile Number
Email
Address
Register