Date:11/22/17

Name (First and Last Name Required):

Address (Required):









Other Required Information:

Gender:

Date of Birth:
//

Email Address:

How did you hear about us?

If other, please list:

Optional Information:

Phone Number:
--

Driver's License or State ID Number:

Ethnicity:

Yes! I want to be an Organ, Tissue & Eye donor.

By submitting this registration I affirm that I am the applicant described on this application and that the information entered herein is true and correct to the best of my knowledge. This registration will serve as a document of gift as outlined in the Louisiana Uniform Anatomical Gift Act. A document of gift, not revoked by the donor before death, is irreversible and does not require the consent of any other person. It also authorizes any examination necessary to ensure the medical acceptability of the anatomical gift.

In order to complete the electronic signature, please enter your Social Security Number and type your name in the signature field. All information submitted will be used only for official Registry business and will be kept completely confidential. We will not share, sell or otherwise compromise this information.

Please enter the last four digits of your Social Security Number or your Individual Taxpayer Identification Number (ITIN):

Signature(type your name):