Register online at
www.donatelifems.org
Or send completed form to
Mississippi’s
MORA
Organ, Tissue and Eye
Donor Registry
Please print clearly and legibly
Midtown Pointe
499 Gloster Creek
Suite D4
Tupelo, MS 38801
662-841-1960
* required to answer
* First Name __________________________________________ Middle ______________________________________
* Last Name __________________________________________ Suffix ______________ (Jr., Sr., II, etc.)
* Mailing Address
* City
________________________________________________________Apartment #______________
___________________________________ * State _________ * Zip _____________
Home Phone (
)
________ - ____________
Cell Phone (
)
________ - _______________
Email Address ___________________________________________
You must be 18 years of age or older to legally enroll in the Mississippi Donor Registry.
* Date of Birth ________ / _________ / _________
*
* Gender _______ Male, _________ Female
Your Drivers License Number or State ID Number ______________________________________
Or the last four numbers of your Social Security Number_____________________________________
How did you hear about the Mississippi Organ & Tissue Donor Registry? Please choose an option:
 Advertisement
 Email/Newsletter
 Facebook
 Twitter
 Magazine Article
 Newspaper
 TV News
 Radio
 You Tube
 Family/Friend
 Search Engine
/ Website
 Other ______________________________________________________________________
When you enroll in Mississippi’s Donor Registry, you are registering as an organ, tissue and eye donor.
I wish to enroll in the State of Mississippi Organ and Tissue Donor Registry maintained by the Mississippi Organ Recovery Agency. I understand that by enrolling in
the registry that I am giving legal consent to the donation of my organs, tissues and eyes (as specified above) in the event of my death. I authorize the Mississippi
Organ Recovery Agency to access this information as needed in administration of the registry, and to share this information at or near the time of my death with
federally regulated organ procurement organizations. I wish to donate (please circle): organs
tissues
eyes. If nothing is circled you are registering as an
organ, tissue and eye donor.
_________________________________________________________________________________
Signature
_____________ / ____________ / _____________
Date
Registration Location / Event Name _______________________________________________________________________________________________________
Form No. ED-F-1