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Donor Registration
 
Name
:
*
*Gender
:
Male
 
Female
Date of birth
:
Select Date *
Weight (in Kg.)
:
Blood Group
:
*
State
:
*
District
:
*
Location (Kollam Only)
:
Telephone (With STD Code Eg. 04742792819)
:
Mobile Number (10 Digits Only)
:
*
Address
:
E_Mail:
:
Last Donation Date
:
*Enter the letters from the image
 
Security Image

Tick here to Agree and then submit

I here by declare that information furnished above is true to the best to my knowledge & i am willing to disclose my mobile/phone no. 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.

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