Welcome to Blood Donor Registration

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
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.