Annexure - A APPLICATION FORM FOR STRENGTHENING OF AN EYE BANK/EYE DONATION CENTRE IN VOLUNTARY SECTOR (To be filled in by the Vol. Organisation applying for grant from the Govt. of India under National Programme for Control of Blindness for strengthening of eye banks) 1. Name of the Eye Bank / Organisation :- Year of establishment _____________________________ Act under which registered _________________________ 2. Total No. of persons registered / pledges for eye donations :- 3. No. of eyes (not pairs) Collected / Utilised during the last 4 years Year Collected Utilised 4. No of eyes distributed Sl.No. Name of organisation No. of eyes (a) (b) (c) 5. Existing infrastructure: S.No. Item Availability (Yes/No) Items on which grant to be utilised 1. Building / room 2. Refrigerator 3. Preservation Media 4. Autoclave facilities 5. Enucleation sets 6. Containers for corneal set 7. Transport (Vehicle) 8. Corneal Sets 9. Autoclaves 10. IEC Material 11. Audio-visual Equipment (specify) 12. Slit lamp Microscope 13. Laminer Flow 14. Operating Microscope 6. Area / Population to be covered Population I) Urban (Name of Mohallas Streets) ------------------------------------------ II) Rural (Name of villages) ------------------------------------------ 7. Details of manpower with qualifications and experience : - S.No. Designation Qualifications Experience 1. 2. 3. 4. 8. Brief activities of the Vol. Orgns. Relating to eye bank. 9. I) Total income during the last year Rs.-------------------- II) Total expenditure during the last year Rs.-------------------- III) Total asset at end of last year Rs.-------------------- 10. Certificates / documents to be enclosed : a) Society Registration Certificate under Registration of Societies Act.1860 or any other Statute b) Certificate issued by Eye Bank Association of India c) List of executive members of the Organisation d) Annual report of the Orgn. for the last year e) Audited statements of Accounts for the last year (i.e., income & exp. account, receipt and payment account and balance sheet) We certify that all the information provided in this proforma is correct to the best of my knowledge and belief and nothing has been concealed in it. Signature Signature (Manager of Trust/NGO/ (Officer Incharge Eye Bank) Voluntary organisation) 11. Recommendations of the State Health Department or Director of Health Services of the State/Uts.
