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Phone: +880-02-9669469 , +880-02-9671333
Email: info@orcabloodforlife.org

Online Registration

P E R S O N A L   I N F O R M A T I O N

   
  Name
For Ex-Cadets : Name House/Batch/CadetNumber
 (e.g.: Iftekhar Ahmad T/11/638)
  Mother's Name
  Father's Name
  Postal Address
  Location
  Land Phone (Office)
  Land Phone  (Residence)
  Cell Phone   (EXPOSABLE)
  Email
  Date of Birth
  Sex Male   Female
  Occupation
   

M E D I C A L   &   A D D I T I O N A L   I N F O R M A T I O N

   
  Blood Group
  Weight (in Kg)

  Did you donate blood before?
Yes   No
  If YES,
  How many times?
 
  Last date of blood donation

  In emergency situation are you willing to donate blood any time?

Yes  
No
  If NO,
  Only before
:  

  Are you a member of any other similar association?
Yes   No
  If YES,
  Name of Association

 

 

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