KAIPPATTOOR CLC EYE BANK ONLINE REGISTRATION FORM Eye donation is an act of donating one’s eyes after his/her death. Only corneal blinds can be benefitted through this process not other Blinds. It is an act of charity, purely for the benefit of the society and is totally voluntary. It is done after death. The eye donation of the deceased can be authorized by the next of kith & kin even if the deceased did not pledge to donate his / her eyes before death.  Your eyes can add light to someone's life "Love one another, as I have loved you. No one can have greater love than to lay down his life for his friends." Bible Eligible to donate blood ? Click here.    * Required field cannot be left blank

Name : *

Age *

Date of birth *

01 02 03 04 05 06 07 08 09 10 11 12 MM / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DD / 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 YYYY

Gender *

Select Male Female Rather not say.

Blood Group : *

Select A+ A- B+ B- AB+ AB- O+ O- A1+ A1- A2+ A2- A1B+ A1B- A2B+ A2B- BOMBAY BLOOD GROUP Don't Know Others

If Blood group is others,Specify

Telephone number with STD code :

Mobile Number : *

Email : *

Address Line 1 : *

Address Line 2 :

City/Town : *

State/Region/Province : *

Country *

Select Afghanistan Albania Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia Hercegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D`ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor (Indonesia) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands (Denmark) Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Republic of Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and Mc Donald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (North) Korea (South) Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Monaco Mongolia Montserrat Morocco Mozambique Myanmar Nambia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic Of Moldova Reunion Romania Russia Rwanda Saint Kitts And Nevis Saint Lucia Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands (Inc. Santa Cruz Is.) Somalia South Africa South Georgia And South Sandwich Islands Spain Sri Lankier Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Of America United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Vietnam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe

PinCode *

Occupation :(Optional)

Education :(Optional)

*

I hereby agree that all the information provided by me is correct.

*

"I HAVE WILLINGLY GIVEN THE CONSENT TO DONATE MY EYES AFTER MY DEATH TO ANY EYE BANK IN INDIA THROUGH THIS ON LINE FORM KNOWING THAT MY NAME WILL BE PUBLISHED ON THE WEBSITE AS A PART OF EYE DONATION CAMPAIGN."

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