Enquiry Form
All fields are mandatory

Declaration:

In the hope that I, may help others, I hereby make this anatomical gift, if medically acceptable, to take effect upon my death. The words and marks below indicate my desires.

I give my eyes for the purpose of transplantation, medical research or education. I further direct my next-of-kin herein named to execute this gift after my death. I would like my next-of-kin notified of my pledge to donate. Yes/No

Email: A valid email should be entered.
Subject:
Name of Donor (Mr./Mrs.):
Name of Next-of-kin
Address of Donor:
Address of Next-of-Kin:
Phone no of Donor :
Phone no of Next of Kin:
Birth Date of Donor: