I may need that kidney, but don't have a kegging system to offer, Maybe we can work something out
Please fill out the form below
Instructions: Use a black pen. Answer the multiple choice questions by filling in the box (
before your answer like this::smack: If you are not sure of an answer, leave it blank and we will help you with it during your evaluation.
Todays date:_6-25________________
First name:_Mike_________________ Middle initial:____ Last name:___Pote_______________________________
Maiden name: _____________________________
Social security number:_______-_____-________ Date of birth (month / day / year): _____ / _____ / ______
Sex: xMale Female Age:__29_____
Race: xCaucasian African-American Hispanic Asian-Pacific Other: ______________________
Bank Name _____chase__________________________________________________
Bank routing #____0710000013_________________________________________
Saving/checking account # _I have no money ________________________________________
Citizenship: xUS citizen Permanent resident / Green card Other: ______________________________
Your HOME address: (Street) _______________________________________________________________
(City)_____________________ (State)________________ (Zip)__________________
(Phone #) ( _____ ) ___________________ Cell phone#: ______________________
Email address: ____________________________________
Your WORK address: (Work name)___________________________________________________________
(Street) _______________________________________________________________
(City)_____________________ (State)________________ (Zip)__________________
(Phone #) ( _____ ) ___________________ (FAX #) ( _____ ) __________________
FAMILY doctor: (Name)_______________________________________________________________
(Street) _______________________________________________________________
(City)_____________________ (State)________________ (Zip)__________________
(Phone #) ( _____ ) ___________________ (FAX #) ( _____ ) __________________
I am interested in donating my kidney to:
Recipient: b-boy
First name:__________________ Middle initial:____ Last name:__________________________________
Biological  Adoptive
Other relative: ___________ Close friend Co-worker  Other _________________
 I do not know the recipient very well
 I have never met the recipient
 Drinking buddy
 I met the recipient on a website: _____________________________________