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Name*

Gender* Male Female

Age*

Blood Group* A+ A- B+ B- O+ O- AB+ AB-

Email address

Contact No*

City*

State* Andaman and Nicobar Islands Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chhattisgarh Dadra and Nagar Haveli Daman and Diu Delhi Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Ladakh Lakshadweep Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Odisha Puducherry Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh Uttarakhand West Bengal

Country

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Only for JCI Members

JCI Chapter Name (Optional)

Zone (Optional) None Zone 1 Zone 2 Zone 3 Zone 4 Zone 5 Zone 6 Zone 7 Zone 8 Zone 9 Zone 10 Zone 11 Zone 12 Zone 13 Zone 14 Zone 15 Zone 16 Zone 17 Zone 18 Zone 19 Zone 20 Zone 21 Zone 22 Zone 23 Zone 24 Zone 25

I hereby agree the Terms and that all the information provided by me is correct. I have willingly given the consent to donate my blood through this online form knowing that my name, contact number will be published on this website as a part of Blood Donation Campaign. 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.

Agree & Register

We recommend you enter the Contact No. Which will help us get in touch with you in case you are not reachable by Email. It will be greater help if you could provide us your personal Contact No. besides your corporate Contact No. You can always be reached to save a life!

• Your hemoglobin should not be less than 12.5 grams
• You should be free from acute respiratory diseases and skin diseases
• You should be not carry any disease transmissible by blood transfusion
• You should be not under medication for Malaria / Tuberculosis / Diabetes / Fits / Convulsions
• You should be not suffered from Hepatitis B, C/ AIDS/ Cancer/ Kidney disease/ Heart disease
• Please consult your physician to check for eligibility.

We are very glad that you want to Register as donor. To register as a blood donor is a responsibility. Once you are a registered donor, implies that you will be glad or privileged to donate blood at all possible times.

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