1. Are you eligible to work in the United States?
 
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2. Are you a US citizen or permanent resident?
 
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3. Is your work schedule flexible?
 
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Please provide times when you definately are not available.
4. FIRST name
 
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5. LAST name
 
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6. Street address? (include apartment if approprate)
 
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7. City
 
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8. State
 
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9. Zip Code
 
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10. Home Phone
 
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11. Cell Phone
 
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12. Date of Birth
 
   
13. Height
 
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14. Weight
 
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15. Closest description of your race
 
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If multi-racial, please provide your closest description.
16. Are you adopted?
 
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17. Do you have both ovaries?
 
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18. Have you ever been told you were infertile?
 
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If yes, when and why?
19. Have you ever been diagnosed or told you have polycystic ovarian syndrome or disease (PCOS)?
 
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20. How many pregnancies have you had?
 
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21. How many children do you have?
 
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22. What is your highest level of completed education?
 
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23. Do you smoke?
 
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24. Do you drink alcoholic beverages?
 
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25. Are you currently enrolled as an egg donor in another program?
 
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26. Why do you want to become a donor?
 
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27. How many times have you donated your eggs?
 
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28. What resources influenced or supported your decision to apply to donate your eggs? (obviously FertilityNetwork.com)
 












Please help us by providing any additional detail.
29. What is the ethnic origin of your mother? (e.g. French, Irish)
 
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30. What is the ethnic origin of your father? (e.g. French, Irish)
 
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31. What is your email address for communication with you regarding your pre-screen application?
   
32. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
33. Verify your password.
   

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