Organ Donor Registry Enrollment {BMV 3346}

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 MAILING ADDRESS CITY PHONE DATE OF BIRTH STATE ZIP *STATE OF OHIO DL / ID CARD OR SSN FIRST MIDDLE 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 HEART LUNGS LIVER (AND ASSOCIATED VESSELS) KIDNEYS (AND ASSOCIATED VESSELS) PANCREAS / ISLET CELLS INTESTINES SMALL BOWEL TISSUES EYES / CORNEAS HEART VALVES BONE TENDONS LIGAMENTS VEINS FASCIA SKIN NERVES 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 *In order to make an anatomical gift of your organs, you must have an Ohio driver license or identification card number. 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 The authorization shall remain in effect until withdrawn or amended by the donor.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. BMV 3346 7/15 [760-1541] American LegalNet, Inc. www.FormsWorkFlow.com