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:   Pin:   District:   State:   Tel.(O/R):   Date:   Email: