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. FIRST name
 
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4. LAST name
 
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5. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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6. What is your date of birth?
 
   
7. What is your highest level of completed education?
 
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8. Closest description of your race
 
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If multi-racial, please provide your closest description.
9. Are you adopted?
 
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10. Height
 
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11. Weight
 
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12. Is your work schedule flexible?
 
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13. Do you have both ovaries?
 
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14. Have you ever been told by a medical doctor that you were infertile and/or conceived with fertility treatments?
 
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If yes, please explain.
15. Are your menstrual periods regular (when not on the pill)?
 
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16. Are your currently breastfeeding?
 
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17. Have you ever been treated for any gynecologic problems such as cysts, fibroids, or endometriosis?
 
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If yes, please explain.
18. Have you applied or been screened to be an egg donor before?
 
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If yes, provide the name and location of the donor program(s).
19. How many times have you donated your eggs?
 
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20. Are you currently enrolled as an egg donor in another program?
 
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21. How many cigarettes do you smoke per day?
 
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22. When is the last time you had marijuana?
 
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23. How many drinks do you usually consume in a week?
 
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24. When is the last time you have had a non-medical needle piercing of your body (via acupuncture, tattoo, body piercing, ear piercing, etc.)?
 
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25. Have you spent 3 months or more, cumulatively, in the UK (England, Northern Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar, or the Falkland Islands) from the beginning of 1980 through the end of 1996?
 
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26. Are you a current or former US military member, civilian military employee, or dependent of a military member or civilian employee, who has resided at US military bases in northern Europe (Germany, Belgium, and Netherlands) for 6 months or more cumulatively from 1980 through 1990, or elsewhere in Europe (Greece, Turkey, Spain, Portugal, or Italy) for 6 months or more cumulatively from 1980 through 1996?
 
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27. Have you lived cumulatively for 5 years or more in Europe (Albania, Austria, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Liechtenstein, Luxembourg, Macedonia, Netherlands, Norway, Poland, Portugal, Romania, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, England, Northern Ireland, Scotland, Wales, Isle of Man, Channel Islands, Gibraltar, Falkland Islands, and Yugoslavia) from 1980 until present?
 
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28. Were you or any of your sexual partners born in or have you or any of your sexual partners lived in Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria after 1977?
 
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29. Have you had a past diagnosis of clinical, symptomatic viral hepatitis after your eleventh birthday, unless evidence from the time of illness documents that the hepatitis was identified as being caused by hepatitis A virus (e.g., a reactive IgM anti-HAV test), Epstein-Barr Virus (EBV), or cytomegalovirus (CMV)?
 
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30. Have you ever taken anti-malarial drugs or had malaria?
 
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31. Have you had a blood transfusion?
 
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If yes, when?
32. Have you ever been refused or denied as a blood donor?
 
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33. What resources have influenced your decision to apply?
 
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Please provide which website, radio station, newspaper or person who referred you.
34. What is your email address for communication with you regarding your pre-screen application?
   
35. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
36. Verify your password.
   

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