Accreditation Interest Form

Licenses

Is your organization licensed by, registered with, or have a permit from any state?

Yes

No

Please provide a list of current licenses and registration numbers.

Do you have entities operated by common control, ownership, medical direction or satellite offices under the same corporate structure?

Yes

No

Tissues Handled

Please specify what type(s) of deceased donor tissue your organization handles.

Cardiac Tissue	Cellular Tissue
Musculoskeletal Tissue	Non-Transplant Anatomical (NAM or NTAD)
Skin	Vascular Tissue

Please specify what type(s) of living donor tissue your establishment handles.

Autologous Tissue	Birth Tissue
Reproductive Tissue	Surgical Bone

Does your organization handle Non-Transplant Anatomical (NAM or NTAD) Tissue?

Yes

No

Please specify what activity(ies) your organization performs.

Acquisition (NAM)	Authorization
Distribution	Donor Eligibility Determination
Donor Screening	Informed Consent
Preparation (NAM)	Processing
Recovery	Storage

Describe all non-human tissues handled by your organization.

Background

Organization Founded Date

Have you purchased the current Standards for Tissue Banking or Standards for Non Transplant Anatomical Donation?

Yes

No

When do you intend to apply for Accreditation?

Annual Gross Tissue Revenue

Do you have any questions for the AATB Accreditation Team?

Information will be reviewed and approved by AATB staff prior to distribution any application materials.