This Form is in accordance with the Transplantation of Human Organs Act 1994.

Fields marked with * are mandatory.

1. First Name *
2. Last Name *
3. Father Name
4. Spouse Name
5. Gender * Select Female Male
6. Blood Group Select A+ A- AB+ AB- B+ B- O+ O- Dont Know
7. Email *
8. contact no *
9. Organization
10. Address *

note - please fill in the complete postal address as the pledge cards will be sent by post

11. City *
12. Pin Code
13. State *

14. Witness 1

    Disclaimer: As the family decision is the final decision when it comes to organ donation, we would be sending an automatic email to your witness to inform them of your decision to gift life!

15. Name *
16. Relationship * Select Aunt Brother Brother-in-law Daughter Son Cousin Daughter-in-law Father Father-in-law Mother Mother-in-law Nephew Niece Sister Sister-in-law Son-in-law Husband Wife Uncle Other
17. Address
18. Contact Number
19. Email
20. It is necessary for one of the witnesses to be a close family member.

21. Witness 2

22. Name *
23. Relationship * Select Aunt Brother Brother-in-law Daughter Son Cousin Daughter-in-law Father Father-in-law Friend Mother Mother-in-law Nephew Niece Sister Sister-in-law Son-in-law Husband Wife Uncle Other
24. Address
25. Contact Number
26. Email
27. Organs/ Tissues to be pledged * All suitable organs Bone Eyes Heart Kidneys Liver Lungs Skin Pancreas Heart valves Ear drums Hold Ctrl. Key to select multiple options.

28. Terms & Conditions

29. I hereby unequivocally authorize the removal of my organ / organs, mentioned above from my body after my death for therapeutic purposes.
30. I hereby confirm that I am aware of the importance of having the witness signature on the Pledge card, and I take full responsibility for its implementation
31. I hereby confirm that all the above information is right and I choose to pledge my organs being in the sane state of mind.
32.    I accept terms & conditions *
33.  
34. Verification Code *
    Please type the Verification Code as you see above.
35.