The Gift of Life

"MANY lives
could be saved
if more people
became organ

& tissue donors. 

Thatís why Iím
doing my part to
help in this
important effort.

Please make 
the decision to
become an organ

& tissue donor. 

Itís the right
thing to do."

Michael Jordan
 

sign up!
  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
Email
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.

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