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
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4.
What is your LAST name?
250 characters remaining
""
5.
Street address? (include apartment if appropriate)
250 characters remaining
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6.
City
250 characters remaining
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7.
State
250 characters remaining
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8.
What is the closest major metropolitan city?
250 characters remaining
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9.
Zip Code
250 characters remaining
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10.
Home Phone
250 characters remaining
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11.
Cell Phone
250 characters remaining
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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 -
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
1907
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
Other (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+
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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?
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.
Please add
no-reply@donorapplication.com
to your email contact list to prevent our response from being flagged as spam.
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