Organ Donation Campaign

The Gift of Life

"MANY lives
could be saved
if more people
became organ
& tissue donors.

That’s why I’m
doing my part to
help in this
important effort.

Please make
the decision to
become an organ
& tissue donor.

It’s the right
thing to do."

Michael Jordan

NATIONAL ORGAN DONOR REGISTRATION FORM
Pledge your organs and tissues by filling in this form.
PRINT and MAIL THIS FORM as your signature is required.

1. Y O U R P E R S O N AL D A T A

Name
Identity Card	Old IC New IC
Birthdate	DD MM YY
Race	Malay Chinese Indian Others
Gender	Male Female
Address
Town/City
State

Postcode			Country
Telephone			Fax

2. Y O U R W I S H

To save lives, I request that after my death,
A. ALL my organs and tissues
B. OR Kidneys Heart Liver Lungs Eyes
Bones Skin may be removed for the purposes of transplantation

SIGNATURE:

DATE

3. M Y N E X T O F K I N

Name
Relationship

4. W H A T T O D O N E X T ?

Please let your family know of your decision to be an organ and tissue donor upon death. YOUR SIGNATURE IS REQUIRED.
PRINT and SEND this form to:
Pusat Sumber Transplan Nasional
(National Transplant Resource Center)
Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur
03-2615-5555 ext 6576 (Hospital KL) or 03-26942705.