Making Life Happen
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AMA Saves Lives
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Office of Motor Vehicles
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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:
Signature(type your name):
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Louisiana Organ Procurement AgencyMaking Life Happen
68190 Highway 190 Service Rd. , Covington, LA 70433 | 1-800-521-GIVE (4483)
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