Donor Enrollment Form

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Donor Enrollment Form

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To register, please complete and mail this enrollment form to:

Ohio Bureau of Motor Vehicles
ATTN: Record Clearance Unit
P. O. Box 16784
Columbus, OH 43216-6784 .

Yes, I want to join the Donor Registry!

Please take me out of the Donor Registry

Full Name ______________________________
please print ????First ????????????????????Middle ??????????????????????????Last



Mailing Address __________________________
????????????????????????????????????????????????????????????????????????Street Address

________________________________________
City ??????????????????????????????State ????????????????????????????????????????????????Zip code

Phone ( ) _________ Date of Birth__________

Driver License or ID Card # ________________ .

Upon my death, I make an anatomical gift of my organs, tissues and eyes for any purpose authorized by law.

******** OR ********

Upon my death, I make an anatomical gift of the following specified organs, tissues and/or eyes:

[Specify all organs/tissues to be donated, or indicate ???all???]

______________________________________________

______________________________________________

for any purposes authorized by law: transplantation, therapy, research, education, or advancement of medical or dental science.???

[Please mark a line through any purpose(s) that are not acceptable to you.]

_____________________________________
Signature of Donor Registrant ??????????????????????????????Date

_______________________________________
Witness

______________________________________
Witness

[one witness must be the parent or legal guardian if donor is under the age of 18]

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(740) 374-1400
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