Welcome to Back Alley's Black Market Organs order form.

[By reading this you are not able to sue the company.]

Please fill out our organ harvesting form.

Check ALL the age groups of the donors that you would be willing to take an organ from.

                                                 Healthy male (age 17 to 25) 60,000 Dollars 

                                                 Health female (age 17 to 25) 64,000 Dollars     

                                                 Donor age  50 and up $25,000

                                                 I want to live, just give me an organ! ($250.00)

All prices are in Canadian funds.

 

Number of Organs

Organ type 

Organ type 

Organ type 

Organ type 

Organ type 

 

First NamePostal Code  
Last NameStreet and apt#  
Phone NumberCity and Country  
Do you have any excess organs or body part you would like us to remove free of charge?

yes no

Do you have any family members, friends and or neighbors with healthy organs, that you do not necessarily like? 

Yes?  

Answer who, with a brief physical description and their address.

Please address all questions, comments and ethical concerns to the comment box below.