I Application for Public Organization Membership

Department of Health and Human Services OMB No. 0915-0184

Health Resources and Services Administration Expiration Date: xx/xx/201x

APPLICATION FOR PUBLIC ORGANIZATION MEMBERSHIP

IN THE

ORGAN PROCUREMENT AND TRANSPLANTATION NETWORK (OPTN)

UNOS

700 North 4^th Street

Richmond, VA 23219

Main Phone: (804) 782-4800

Name of Organization:
Address:
City, State, & Zip Code:
Contact Person:
Phone Number:	Email

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 this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, 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 10-29, 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. I understand that the intentional submission of false data to the OPTN may result in action by the Secretary of Health and Human Services, and/or civil or criminal penalties. By submitting this application to the OPTN, the applicant agrees: (i) to be bound by OPTN Obligations, 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.

Date:	Signature:
Print Name:	Title:
Applicant #

Application for Public Organization Membership

1. Provide the following documents:

a) A current roster of the organization/institution's board of directors and officers.

b) A copy of the organization/institution's Articles of Incorporation and Bylaws.

c) A copy of the organization/institution's last annual report or annual financial report.

2. A Public Organization Member is an organization with an interest in organ donation or transplantation and must have been in operation for at least one year. Explain how this organization’s interest in organ donation or transplantation satisfies this requirement:

[Insert detailed response here. Table will expand automatically]

Provide documentation as described in items a, b, or c below:

a) Provide documentation that demonstrates that the hospital refers at least one potential organ or tissue donor per year.

[Insert detailed response here or reference attachment. Table will expand automatically]

b) Describe how this organization/institution meets the requirement for being a non-profit organization or institution that engages in organ donation activities or represents or directly provides support and services to transplant candidates, recipients or their families. Attach a copy of the organization/institution's IRS non-profit status letter.

[Insert detailed response here. Table will expand automatically]

c) Provide letters of recommendation from at least three OPTN members (transplant hospital, OPO, histocompatibility laboratory, public organization, or medical/scientific member). Attach a copy of the organization/institution's IRS non-profit status letter.

version pending Public Organization - 0