REGISTRATION NUMBER ______________ DATE _______________

I, _____________________________________________________________________________

SON/DAUGHTER OF MR.&MRS. ________________________________________________________

EXPRESS MY WISHES IN WRITING, TO PLEDGE MY EYES TO THE Y’S MEN EYE BANK OF

VIRUDHUNAGAR. AFTER MY DEATH, MY EYES MAY BE USED FOR THE BENEFIT OF THE

VISUALLY IMPAIRED.

I AGREE TO THIS. DONOR’S SIGNATURE

(CLOSE RELATIVE)

NAME _______________________________________ NAME_____________________________

SIGNATURE __________________________________ AGE_______________________________

AGE _________________________________________ ADDRESS __________________________

RELATIONSHIP _______________________________ ____________________________________

ADDRESS ____________________________________ PHONE NUMBER ___________________

_____________________________________ __________________________________