Pledge Form
All data entered in this form will remain private and will not be shared with any individual or corporation except NOTTO.
To be filled by an individual of age 18 years or above.
* Required
Country
*
India
Australia
Hong Kong
USA
Canada
UK
Rest of the World
Full name
*
(Will appear on pledge card.)
Son of
Daughter of
Wife of
*
Address
*
Full Address of correspondence
(Will appear on pledge card.)
City
*
Pincode
*
State
*
Date of Birth
*
Age should be 18 years and above
(Will appear on pledge card.)
Email
Confirm Email
I hereby authorise the removal of the following organs from my body after my death, which may be used for therapeutic purposes.
*
I confirm I have read the above
ORGANS PLEDGED
*
(Will appear on pledge card.)
Any suitable organs & tissues
OR
Eyes
Skin
Kidneys
Liver
Heart
Lungs
Pancreas
Bones
OTHER INFORMATION
Blood Group
*
A+
A-
B+
B-
AB+
AB-
O+
O-
(Will appear on pledge card.)
Government Approved ID
Passport
Driver's License
Aadhar/UID
Government Employment ID
PAN Card
Voter ID
ID No
Mobile No
*
Phone No
Date of Pledge
*
Place
*
Signature
*
IN CASE OF EMERGENCY
* Out of the two, at least one needs to be a close relative.
EMERGENCY CONTACT - 1
Full name
*
(Will appear on pledge card.)
Son of
Daughter of
Wife of
*
Age
*
Age should be 18 years and above
Address
*
Same As Donor Address
Mobile No
*
(Will appear on pledge card.)
Phone No
Email ID
EMERGENCY CONTACT - 2
Full name
*
Son of
Daughter of
Wife of
*
Age
*
Age should be 18 years and above
Address
*
Same As Donor Address
Mobile No
*
Phone No
Email ID
PLEASE NOTE
We will issue a pledge card on the basis of information provided. The card is not a legal document, but an acknowledgement of your wish to donate your organs.
Remember that your family and dear ones would be the ones who will give the final consent for organ donation after your death.
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