Name: Lions Eye Bank for Long Island
Address: 900 Franklin Avenue, Valley Stream, NY, 11580
Telephone: (516) 256-6661

Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Date Of Birth
Eye Color*
Height (feet / inches)*
Gender*
- Male
- Female
9-digit DMV license or non-driver DMV ID #*
I offer the donation of:*
- All organs, tissues, and eyes
- Limited organs, tissues and eyes as specified below
Please check the boxes of the limited organs and tissues that YOU WISH TO DONATE:
I offer the donation of:*
- Bone and Connective Tissue
- Corneas
- Eyes
- Heart (for Valves)
- Heart with Connective Tissue
- Kidneys
- Liver / Iliac Vessels
- Lungs
- Pancreas (with Iliac Vessel)
- Skin
- Small Intestine
- Veins
Please check the boxes of the limited organs and tissues that YOU WISH TO DONATE:
I wish to donate the organs and/or tissues specified above for:*
- Transplantation and Research
- Transplantation Only
- Research Only
Please print out this form, sign and date it and mail to: Lions Eye Bank for Long Island North Shore-LIJ Health System 900 Franklin Avenue Valley Stream, NY 11580

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