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Pledge Organ
Pledge Your organs - Primary Information
Fill up the form and we'll send your pledge organ donor card with you.
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* Indicates required question
Initiative to reduce the pain and suffering by enrolling many for optimum use of organs after death.
Full Name
*
Your answer
Son or Daughter of
*
Your answer
Surname or Family Name
*
Your answer
Age
*
Your answer
Address
*
Pledge Organ card also act as a Emergency Card and if lost someone who finds it can send at your home
Your answer
Pin Code Number
*
Your answer
Blood Group
*
A +VE
A -VE
B +VE
B =VE
AB +VE
AB -VE
O +VE
O =VE
Bombay Blood Group
Other:
Required
Mobile Number
*
Your answer
Email Address
*
Use Valid Email Address so we can mail you soft copy of Pledge Card
Your answer
I am interested in donating below tissue after my normal death
*
Eye
Skin
Bone Marrow
Heart Valve
Bone
Tendon and Ligaments
Other:
Required
I am interested in donating below organ after my brain death
*
Kidney
Liver
Heart
Lung
Intestine
Pancrease
Spleen
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