my eye donation form

Eyes can be donated to any eye bank in India. Eye donation needs the consent of relatives. Please print this card, sign it and keep always with you. Please do not misplace this card.
Eye Bank Association of India, Toll Free No. 1919 / 1053 Email : ebai@vsnl.net Website : www.ebai.org
VYANKATESH PARIWAR E-mail : vyankateshpariwar@rediffmail.com Website : www.donateeys.org
I have pledged that my eyes be donated within 6 hours of my death. I have informed my relatives about my decision. My relatives will inform any near by eye bank after my death.
Name :	c s marimuthu
Address :	4th street,periyarnagar ext,madipakkam
City :	CHENNAI
Pin Code :	600091
Mobile :	9600242717
Date of Birth :	22/12/1991
Date of Pledge :	12/12/2012
Signature