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Department of Health and Human Services
Health Resources and Services Administration

OMB No.Pending
Expiration Date: Pending

APPLICATION FOR PUBLIC MEMBERSHIP AS A
MEDICAL/SCIENTIFIC ORGANIZATION
IN THE
ORGAN PROCUREMENT AND TRANSPLANTATION NETWORK (OPTN)
UNOS
700 North 4th Street
Richmond, VA 23219
Main Phone: (804) 782-4800

Name of Organization

________________________________________________________________

Address:

________________________________________________________________

City, State, & Zip Code: _________________________________________________________________
Contact Person:

_______________________________________________________________

Phone Number:

(______)____________________

PUBLIC BURDEN STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond
to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for
this project is 0915-0184. Public reporting burden for the applicant for this collection of information is estimated to
average 10 hours per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland
20857.
CERTIFICATION
The undersigned, a duly authorized representative of the applicant, does hereby certify that the answers and
attachments to this application are true, correct and complete, to the best of his or her knowledge after investigation.
By submitting this application to the OPTN, the applicant agrees: (i) to be bound by the Organ Procurement and
Transplantation Network's rules and regulations, including amendments thereto, if the applicant is granted
membership and (ii) to be bound by the terms, thereof, including amendments thereto, in all matters relating to
consideration of the application without regard to whether or not the applicant is granted membership.

Signature:

_____________________________________________

Date: _______________________

Print Name:

______________________________________________

Title:

Member Code: _____________

version date pending

______________________

Instructions

1.

The Criteria for Public Membership are found in the OPTN Charter, Article IV Membership.

2.

By submitting this application to the OPTN, the applicant acknowledges that its duly
authorized representatives have received and read the current Charter and By-Laws of the
OPTN and the applicant agrees: (i) to be bound by the terms thereof, including
amendments thereto, if the applicant is granted membership and (ii) to be bound by the
terms thereof, including amendments thereto, in all matters relating to consideration of
the application without regard to whether or not the applicant is granted membership.

3.

A duly authorized representative of the applicant must review the answers and
attachments to the Application, perform sufficient investigation to determine accuracy
and completeness, and sign and date the Certification on the cover page of the
Application. Failure to furnish accurate and complete information in connection with the
Application and subsequent requests for supplemental information, constitute grounds for
denial or suspension of OPTN membership.

4.

Application responses must be typed and complete.
- Do not submit two-sided pages.
- Attach additional pages as necessary and reference the question and page number
on each attachment.

5.

Return the original application and one (1) complete copy. Please also return a copy of the
application that has been scanned to a CD in PDF format. Label the CD with the
Organization name, contact name, and date, and include an electronic table of contents.

Express Mail:
UNOS
Administrator, Membership Services
700 North 4th Street
Richmond, VA 23219
Main Phone: (804) 782-4800

version date pending

US Mail:
UNOS
Administrator, Membership Services
PO Box 2484
Richmond, VA 23218

Application for Medical/Scientific Organization Membership

1.

2.

Provide the following documents:
a)

A current roster of the organization's board of directors and officers.

b)

A copy of the organization’s Articles of Incorporation and By-laws.

c)

A copy of the organization’s IRS non-profit status letter.

d)

A copy of the organization’s last Annual report(s)

A Medical/Scientific Member shall be “an established, non-profit organization or
institution with at least one year of operating history that has an interest in the fields of
organ donation or transplantation, defined as” item a or b below:

a)

Describe how this organization/institution meets the requirement for being “An
organization or institution that serves as a medical or scientific membership
organization and includes within its membership professional members who are
involved in organ transplantation.” Alternatively, provide the documentation as
described in question 2b (below.)

b) An organization or institution that is supported by letters of recommendation for
OPTN membership from at least three other OPTN member organizations or
institutions, each of which meets the criteria for Institutional Membership listed in
Article IV.
Med/Sci-1

version date pending