1. Are you a US citizen or permanent resident?
 
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2. Are you eligible to work in the United States?
 
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3. What is your FIRST name?
 
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4. What is your LAST name?
 
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5. Street address? (include apartment if appropriate)
 
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6. City
 
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7. State
 
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8. What is the closest major metropolitan city?
 
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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. What is your height?
 
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14. What is your weight?
 
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15. What race would you most likely be affiliated?
 
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Please Explain
16. Are you adopted?
 
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17. How many pregnancies have you had?
 
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18. How many children have you given birth to?
 
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19. What is your highest level of completed education?
 
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20. Do you currently smoke cigarettes?
 
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21. Do you drink alcoholic beverages?
 
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22. Why do you want to become a donor?
 
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23. How many times have you donated your eggs?
 
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24. Are there any genetic diseases that run in your family? If so, please explain.
 
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If yes, please explain.
25. Are you willing to administer self injectable medications for up to four weeks?
 
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26. What resources have influenced your decision to apply?
 









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?
   
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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