South Dakota Driver License / I.d. Card Application Form (Page 2 of 2) in pdf

ORGAN DONATION CERTIFICATION



In the event of my death, I would like to be an organ/tissue donor.

I acknowledge that I have reviewed the following statements regarding donation.

_____________________________________________________________________

________________________________________________

Signature

Date

Organ, tissue, and eye transplantation are successful, routine procedures that save or improve the lives of thousands of people each year. Unfortunately, there

are many more people waiting for transplants than there are organs and tissues available. The cure to this crisis is an increased commitment to donation. One

organ and tissue donor can save or improve the lives of up to 60 people.

Organs and tissues that can be donated include heart, lungs, liver, kidneys, pancreas, intestines, corneas, skin, heart valves, bone, and connective tissue.

Once a donor is identified, donation coordinators obtain a medical/social history from the next-of-kin and conduct thorough tests to determine medical suitability

of the organs. Additional tissue testing is conducted in order to place the organs with the most appropriate match.

Recovery of organs and tissue is a surgical procedure. Donors are treated with great care and dignity. The donation process does not preclude an open casket

funeral.

All costs related to donation are recovered by the procurement organization which passes those costs along to the transplanting facility. No charges related to

the donation are incurred by the donor or the donor’s family.

For more information about donation, please call 1-888-5-DONATE.

In South Dakota when you indicate on your license or identification card that you wish to give the precious gift of life by being an organ and tissue donor, you

are relieving your loved ones of the burden of making that decision for you at the time of your death.

If at some future time, you decide to amend or revoke your gift of life, you may do so by removing the organ donor designation from your driver license or non-

driver identification card. For more information regarding amending or revoking your gift of donation, please refer to South Dakota Codified Law Chapter 34-26.

PARENTAL CONSENT MUST BE FILLED OUT AND SIGNED BEFORE A NOTARY PUBLIC OR DRIVER EXAMINER

I certify that I am a Parent/Guardian of (print name) ________________________________________________________________________________________________________

and I hereby grant permission for him/her to:

(Check all that apply)

____ Apply for a South Dakota driver license or permit under the requirements of South Dakota law;

____ Apply for a South Dakota non-driver identification card under the requirements of South Dakota law;

____ Have the organ donor indicator placed on the driver license, permit, or non-driver identification card.

Parent/Guardian Signature ___________________________________________________

Print Name ___________________________________________________________

Present Address ___________________________________________________________

City, State, & Zip Code __________________________________________________

Subscribed and sworn to before me on this_____day of _____________________ , 20____

____________________________________________________________________

Notary Public or Driver Examiner

My Commission Expires:

State of South Dakota

LOST LICENSE/IDENTIFICATION CARD CERTIFICATION

If you are applying for a duplicate, renewal or transfer of your driver license or identification card, and have lost the last driver license/identification card issued

to you, complete this section:

I have lost or destroyed the last driver license or identification card issued to me by the state of ________________________ and it is not now in my

possession. I fully realize that by making this statement, said license/identification card is null and void and may not be used for operating a motor vehicle or for

identification purposes.

Signature ______________________________________________________

EXAMINER USE ONLY

RESTRICTIONS (circle)

O F G V X R M E Z B J K W Q

3RD PARTY CDL _____

COMPLETION DATE ______________________

VISUAL ACUITY

DRIVERS ED _____

COMPLETION DATE ______________________

MC SAFETY _____

COMPLETION DATE ______________________

LEFT EYE

BOTH EYES RIGHT EYE

GK _____

COMPUTER CHECKS: CDLIS _____ PDPS _____ SAVE _____

20/

CV _____

SSN _____

AB _____

TEST REQUIRED: VISION _____ KNOWLEDGE_____ SKILL_____

DT _____

____ W/0 CORR LENS ____ WITH CORR LENS

KNOWLEDGE TEST _______________

TK _____

HZ _____

SKILLS TEST _______________

NEW ____ RENEWAL ____ DUP ____

PV _____

FEE COLLECTED __________ Q_____ C_____ EXAMINER ID________

SB _____

TRANSFER ____ DATA CHANGE ____

LICENSE SURRENDERED? _______________

STATE __________

CLASS __________

COMPLIANT __________ NON-COMPLIANT __________

Documents Presented

U.S. Citizen

Non-Citizen

Social Security

____ Compliant DL/ID

____ Perm Res. Card

____ SS Card

____ U.S. Birth Certificate

____ Foreign Passport & I-94

____ W-2 Form

____ U.S. Marriage Certificate

____ Emp. Auth. Doc.

____ 1099 Form

____ U.S. Passport

Address

____ Payroll stub

____ Certificate of Birth Abroad

____ Address docs

____ Citizen/Natural. Cert.

Notes: ________________________________________________________________________________________________

_____________________________________________________________________________________________________

200,000 copies were printed on recycled paper by Register Lakota Printing at a cost of $.014 cents per copy per SDCL 5-18D-15

05-12

South Dakota Driver License / I.d. Card Application Form Page 2

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