Donor Registry Enrollment Form (Optional) Page 3

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DONOR REGISTRY ENROLLMENT FORM (OPTIONAL)
(name of donor)
INSTRUCTIONS:
If you have not already registered as a donor with the Ohio Bureau of Motor Vehicles when
renewing a license or State ID, the “Ohio Donor Registry Enrollment Form” must be fi led with the
Ohio Bureau of Motor Vehicles to ensure that your wishes concerning organ and tissue donation
will be honored. This document will serve as your consent to recover the organs and/or tissues
indicated at the time of your death, if medically possible. In completing this form, your wishes
will be recorded in the Ohio Donor Registry and will be accessible only to the appropriate organ,
tissue or eye recovery organizations. Be sure to share your wishes in this area with loved ones and
friends so they are aware of your intentions. The form can also be used to amend or revoke your
wishes for donation.
To register for the Ohio Donor Registry, please complete this form, detach and send the original
to:
Ohio Bureau of Motor Vehicles
ATTN: Record Clearance Unit
P.O. Box 16583
Columbus, Ohio 43216-6583
Make a copy of this form and retain it with other important documents such as a Living Will
Declaration or Healthcare Power of Attorney. Keep these forms accessible in case of emergencies.
[This form should be used to state your intentions to be included in or removed from the Ohio Bureau of
Motor Vehicles Donor Registry.]
Print or Type Full Name of Donor
Mailing Address
City
State
Zip
Phone (
)
Date of Birth
Driver’s License or ID Card Number
Social Security Number (optional)
Donor Registry Enrollment Form
Page One of Two

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