Personal and Contact Information Form Washington State University

Personal and Contact Information Form
Washington State University
College of Medical Sciences
Willed Body Program
PO Box 643510, Pullman, WA 99164-3510
509-368-6600
Full name of donor (print)
Date
Phone number
Email address
Current address
City
State
County of residence
Zip
Within city limits: Yes 
No 
U.S. citizen: Yes 
No 
Length of time at current residence
Male 
Date of birth
Month
Day
Female 
Year
Place of birth
City
County
State
U.S. Veteran: Yes 
Social Security Number
Marital status:
Single 
Married 
Widowed 
Divorced 
Surviving spouse’s name (wife’s maiden name)
First
Middle
Last
Primary occupation
Type of business/industry
Highest level of education/degree
Ethnicity: White 
Black  Asian  Hispanic  Native American  Other
Donor’s father’s name
First
Middle
Last
Donor’s mother’s maiden name
First
Middle
Last
No 
Next of Kin/Executor of Estate Contact Information
Name
Relationship to donor
Address
City
State
Zip
State
Zip
Phone number(s)
Email address
Alternate Contact Information
Name
Relationship to donor
Address
City
Phone number(s)
Email address
 Please mail all original forms to:
Washington State University
College of Medical Sciences
Willed Body Program
PO Box 643510, Pullman, WA 99164-3510
 Make photocopies for your records, your family, and your physician
 If you have additional questions, please call 509-368-6600