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Department of Health and Human Services
Health Resources and Services Administration

OMB No. pending
Expiration Date: pending

APPLICATION FOR INDIVIDUAL MEMBERSHIP
IN THE
ORGAN PROCUREMENT AND TRANSPLANTATION NETWORK
(OPTN)
UNOS
700 North 4th Street
Richmond, VA 23219
Main Phone: (804) 782-4800

Name of Applicant

________________________________________________________________

Address:

________________________________________________________________

City, State, & Zip Code: _________________________________________________________________
Phone Number:

(______)____________________

Email Address: __________________________________

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 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 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 Individual Membership are found in the OPTN Charter, Article IV Membership.

2.

By submitting this application to the OPTN, the applicant acknowledges that they have
received and read the current Articles of Incorporation 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.

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 two (2) complete copies to:
Express Mail:
UNOS
Administrator, Membership Services
700 North 4th Street
Richmond, VA 23219

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

Main Phone: (804) 782-4800

Version Date pending

Name of Applicant: _____________________________________________________________

Individual Members. An Individual Member shall be a person with an interest and/or expertise
in the fields of organ donation or transplantation.

Part 1
Please answer at least one of the Questions 1-5
1.

Do you presently serve or have you formerly served on the OPTN Board of Directors, or
an OPTN Committee. ____ Yes
____ No.
If “Yes,” indicate the name of the specific Committee (or Board) and the term(s) of
service.

2.

Are you or a family member A transplant candidate?
Transplant recipient?
Organ or tissue donor?

3.

Self ___
Family ____ Organ ____
Self ___
Family ____ Organ ____
Self ___
Family ____
(check all that apply)

Are you presently employed by or are independent contractors with OPOs, Transplant
Hospitals, or Histocompatibility Laboratories? ____ Yes
____ No.
If Yes, please explain.

Individual -1
Version Date pending

4.

Were you formerly employed by or were formerly an independent contractor with OPOs,
Transplant Hospitals, or Histocompatibility Laboratories? ____ Yes ___ No
Were you formerly employed by Federal or State government agencies involved in the
field of organ donation and transplantation? _____ Yes
_____ No
If you answered “yes” to either one or both of these questions, explain how you have
continued to demonstrate an active interest in and involvement with the fields of organ
donation or transplantation.

5.

Do you have an active interest in and involvement with the fields of organ donation or
transplantation?
If so, this must be demonstrated by letters of recommendation for OPTN membership
from at least three persons, each of who meets the criteria for Individual Membership
listed in Article IV in the Charter. Please attach these letters of support.

Individual -2
Version Date pending

Part 2
6.

Attach a copy of your resume or curriculum vitae.

7.

Explain your reason for wanting to be an Individual Member of the OPTN.
(Please confine your statement to one page)

Individual - 3
Version Date pending