New York State Donate Life Registry

NYS DONATE LIFE REGISTRY PARTNER APPLICATION, PART 1

Click here to learn more about becoming a New York State Donate Life Registry Partner.

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Business Entity Information

Legal Business Name* Address of the Principal Place of Business*

City*

State*

Zip*

E-mail Address* Telephone* Website*

List any other DBA, Trade Name, Other Identity, or EIN used in the last five (5) years, the state or county where filed, and the status (active or inactive): (if applicable)

Business Entity Type*

Organ and/or Tissue Recovery Organization

Hospital/Healthcare System

State Agency

County Agency

Other

Authorized Contact

First Name*

Last Name*

Title*

Telephone*

E-mail Address*

Enrollment Resource Requested: Select all that apply*

Custom Link learn more

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URL of webpage(s) where promotional tool will be used*

Technical Contact

First Name*

Last Name*

Email*

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