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