Name *
Gender *
Date of birth *
Weight (in Kg.) *
Blood Group *
Location (Kozhikode Only)
Mobile Number *
Job & Company
Last Donation Date

I here by declare that information furnished above is true to the best to my knowledge.

If any of the above information is found to be wrong, I will be

solely responsible for anything resulting out of it and any loss or damage

sustained to the Government or any other person or agency.