Donate Life America
PLEASE PROVIDE ONE OF THE FOLLOWING:
or  
or  
 
I would like to donate:


 
Electronic Signature Certification
I understand this online registration remains binding after my death. I do solemnly swear, affirm or certify that I am the applicant described in application, and that the information entered herein is true and correct. By clicking the submit button I affirm that I wish to be a potential organ donor and/or tissue donor upon my death.

Yes, I accept the Electronic Signature Certification.
 
 
In order to proceed, you must click both the Electronic Signature Certification box AND the “I’m not a Robot” box. The Electronic Signature Certification is your legal acknowledgement of registration. The “I’m not a Robot” box is an extra security feature that helps safeguard data. Both are needed to proceed.