Eye Donor Pledge

In the hope that I may help others I hereby make this gift, if medically acceptable, to take effect upon my death. The submission in the form indicate my desires. I give my eyes for the purpose of transplantation, medical research or education.

Name of Donor(Required)

Prefix First Last

Address of the donor(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of birth(Required)

Phone(Required)

Email(Required)

I further direct my next of kin, herein named, to execute this gift after my death.

Name of the next-of-kin(Required)

Prefix First Last

Address of the next-of-kin(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone of the next-of-kin(Required)

Email of the next-of-kin(Required)