Become A Donor

  • Personal Information

  • Emergency Contact (such person should not be participant of the event)

  • Organisation information

  • Occupation (Tick any one)

  • In the presence of person mention below hereby equivocally authorise the removal of following organ(s)d/or tissue(s), from the body after being declared brain stem dead by the board of medical experts and consent to donate the same for therapeutic purposes.

  • Please Tick Applicable

  • Name of Witness

  • Note:

    1) Organ Donation is a family decision. So it is important that you discuss your decision with family members and loved ones so that it will be easier for them to follow through with your wishes.
    2) The person making the pledge has the option to withdraw the pledge.
    3) After filling the form, Kindly send it to Donate Life, on address mention below.
  • "Donate Life"

    Opp. IDBI Bank, Nr. Kasanagar, Katargam, Surat-395004, Gujarat, India.
    Phone No: +91-7573011101/03/06/07
    Toll Free Number: 1800 200 1944