01-DKM-0226-00002 tif Pdf Compressor-1087320

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BLOOD CANCER

DKMS 1166867-O

1166867-O

J Bone Mar U.S.

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Donor Registration Form rmanent contact information.

residents only.

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We con only register you if you provide ALL the details below.

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Choose a friend or relative who does not live with you, who will know how to reach you in the future should we be unable to contact you otherwise.

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patients match with donors who share the same ancestry and/or ethnicity. Knowing your background can enhance patients' If you are not sure of your heritage, think about where your grandparents or great-grandparents came from originally.

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which groups) are

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Black/African Descent

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Donor Statement of Eonsent

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My signature indicates that:

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(hove read Form IB [Rev 05/141 on the bock of thisform and consent to its terms. / hove provided accurate b'nd comp/ere cantatI ¡nf ormotian.

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(have read Ehe educar/ono! material provided and was given the opportunity to oak queatìons.

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/consent

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consent ta having my cheek swab tored.

by Oelete abad cancer OKt45 to be available far passible/uture testing ta determine/f

match a searching patient-

Date

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