Congratulations! on taking the first step in spreading the gift of sight. We can assure you there can be no other cause that is nobler. Please fill out these details below and we will send across this information to the nearest eye bank, which will then provide you with the eye pledge card.

More importantly, please ensure all your family members, near and dear ones are informed about your desire to donate your eyes, because if they do not give their consent, this pledge form will be rendered useless.

Name
Age
Gender		MaleFemale
Street Address
State		- Select State - Andaman & Nicobar Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chhattisgarh Dadra & Nagar Haveli Daman & Diu Delhi Goa Gujarat Haryana Himachal Pradesh Jammu & Kashmir Jharkand Karnataka Kerala Lakshadeep Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Pondicherry Punjab Rajasthan Sikkim Tamil Nadu Tripura Uttar Pradesh Uttaranchal West Bengal
City		-- Select City --
Pincode
Phone
E-mail

* Please allow 4 to 6 weeks for the delivery of your eye pledge card.

Locate Your Nearest Eye Bank
Andhra Pradesh Assam Bihar Chandigarh Delhi Gujarat Haryana Karnataka Kerala		Madya Pradesh Maharashtra Orissa Pondicherry Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal

Note: Due to frequent changes in telephone numbers, there could be errors in the numbers listed here. Kindly consult the local telephone directory or information center for the changed telephone numbers. Also, in case you come across a number that has changed or is non-existent, please do mail us the changed number so that we could update these records. Thank you.