Department of Public Safety | Ohio.gov
|[pic] |OHIO DEPARTMENT OF PUBLIC SAFETY | |
| |BUREAU OF MOTOR VEHICLES | |
| | | |
| |ORGAN DONOR REGISTRY ENROLLMENT | |
| |
|To register, please complete and mail this enrollment form to: |
| |
|Ohio Bureau of Motor Vehicles |
|Attn: BMV Records |
|P.O. BOX 16520 |
|Columbus, OH 43216-6520 |
| |
|PLEASE PRINT |
|LAST NAME |FIRST |MIDDLE |
| | | |
|MAILING ADDRESS |
| |
|CITY |STATE |ZIP |
| | | |
|PHONE |DATE OF BIRTH |*STATE OF OHIO DL / ID CARD OR SSN |
| | | |
| |
|DONOR REGISTRY ENROLLMENT OPTIONS |
|OPTION 1 |
| Upon my death, I make an anatomical gift of my organs, tissues, and eyes for any purpose authorized by law. |
|OPTION 2 |
| Upon my death, I make an anatomical gift of the following organs, tissues, and / or eyes selected below: |
| ALL ORGANS, TISSUES AND EYES |
|ORGANS |TISSUES |
| HEART | INTESTINES | EYES / CORNEAS | VEINS |
| LUNGS | SMALL BOWEL | HEART VALVES | FASCIA |
| LIVER (AND ASSOCIATED VESSELS) | | BONE | SKIN |
| KIDNEYS (AND ASSOCIATED VESSELS) | | TENDONS | NERVES |
| PANCREAS / ISLET CELLS | | LIGAMENTS | |
|For The Following Purposes Authorized By Law: |
| ALL PURPOSES | TRANSPLANTATION | THERAPY | RESEARCH | EDUCATION |
|OPTION 3 |
| Please remove my name from the Ohio Donor Registry. |
| |
|SIGNATURE OF DONOR REGISTRANT |DATE |
|X | |
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|*In order to make an anatomical gift of your organs, you must have an Ohio driver license or identification card number. |
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|In accordance with Ohio Revised Code Section 2108.05(C), once you have consented to make an anatomical gift to be displayed on your Ohio driver's license or |
|identification card, there is no reconfirmation requirement to make an anatomical gift upon renewal of your Ohio driver's license or identification card. The |
|authorization shall remain in effect until withdrawn or amended by the donor. No other person is authorized to amend or revoke an anatomical gift on behalf of the |
|donor. |
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