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Godavari Ben And Anupchand Shah Eye Bank - Pledge Form
(A unit of Rotary Narayana Nethralaya)

FAMILY PLEDGE FORM FOR EYE DONATION
   
In the hope that I/We may help others. I/We hereby make this anatomical gift, if medically acceptable, to take effect upon my/our death. The statement below indicates my/our desire(s).
   
I and the following members of our family give my/our eyes for the purpose of transplantation, therapy, medical research of education.
   
Relationship/ Witness Self   Name in Block Letters   Date of Birth
Mr/Ms  
Mr/Ms  
Mr/Ms  
Mr/Ms  
Mr/Ms  
Mr/Ms  
Mr/Ms  
Mr/Ms  
Mr/Ms  
Mr/Ms  
Mr/Ms  
   
Address:  
City:  
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State:  
Tel.(O/R):  
Date:  
Email:    

 
 
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