1. Are you a US citizen or permanent resident?   Yes No ""  2. Are you eligible to work in the United States?   Yes No ""  3. What is your FIRST name?   250 characters remaining ""  4. What is your LAST name?   250 characters remaining ""  5. Street address? (include apartment if appropriate)   250 characters remaining ""  6. City   250 characters remaining ""  7. State   250 characters remaining ""  8. What is the closest major metropolitan city?   250 characters remaining ""  9. Zip Code   250 characters remaining ""  10. Home Phone   250 characters remaining ""  11. Cell Phone   250 characters remaining ""  12. Date of Birth   - Month - January February March April May June July August September October November December   - Day - 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   - Year - 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 13. What is your height?   4'08" 4'09" 4'10" 4'11" 5'00" 5'01" 5'02" 5'03" 5'04" 5'05" 5'06" 5'07" 5'08" 5'09" 5'10" 5'11" 6'00" 6'01" 6'02" 6'03" 6'04" 6'05"+ ""  14. What is your weight?   <90 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 205 210 215 220 225 230 235 240 245 250 255 260+ ""  15. What race would you most likely be affiliated?   African American American Indian Caucasian Chinese Hispanic Indian (from India) Jewish Mediterranean Southeast Asian Asian Other (explain) Multi racial (explain) ""  Please Explain 16. Are you adopted?   No Yes (but know family genetics and history) Yes (do not know family genetics and history) Don't Know ""  17. How many pregnancies have you had?   0 1 2 3 4 5 6 7 8 9 10+ ""  18. How many children have you given birth to?   0 1 2 3 4 5 6 7 8 9 10+ ""  19. What is your highest level of completed education?   GED high school diploma some college college diploma some post graduate post graduate degree doctorate ""  20. Do you currently smoke cigarettes?   Daily Occasionally Rarely Never ""  21. Do you drink alcoholic beverages?   No Rarely Seldom Frequently 1/week 2/week 3/week 4/week 5/week >5/week ""  22. Why do you want to become a donor?   250 characters remaining ""  23. How many times have you donated your eggs?   0 1 2 3 4 5 6+ ""  24. Are there any genetic diseases that run in your family? If so, please explain.   Yes No ""  If yes, please explain. 25. Are you willing to administer self injectable medications for up to four weeks?   Yes No ""  26. What resources have influenced your decision to apply?   FertilityNetwork.com Craigslist.com Doctor's Website Egg Donation Website Other Internet Radio Newspaper Friend Our Employee Other Please provide which website, radio station, newspaper or person who referred you.

27. What is your email address for communication with you regarding your pre-screen application?     27. Please verify your email address     28. What is your preferred password for future login reference?    (6-20 characters with 4 or more letters and 1 or more numbers)   29. Verify your password

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