i WILL to Touch Lives
Pledge Form for Organs, Skin & Eye Donation - an Initiative of Rotary Club of Bombay West
I hereby unequivocally authorize the removal of my ORGANS (only after I am declared brain stem dead), AND/OR my SKIN & my EYES from my body for therapeutic purposes after my death (caused due to any reason) *
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My Full Name Is *
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My Father's / Husband's Name *
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My Age (in completed years) *
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My Residential Address *
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City
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Pincode *
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My Email ID
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My Phone No. *
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My Blood Group Is
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