Donate Life NY

NYS DONATE LIFE REGISTRY PARTNER APPLICATION, PART 1

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

Already an existing partner? Click here to access your partner reports.

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*

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NYS DONATE LIFE REGISTRY PARTNER APPLICATION, PART 1

Business Entity Information

Authorized Contact

Technical Contact

Registro de Donación de Órganos del Estado de Nueva York