1. Are you adopted?
 
"" 
2. Are you a US citizen or permanent resident?
 
"" 
3. Are you eligible to work in the United States?
 
"" 
4. What is your FIRST name?
 
250 characters remaining "" 
5. What is your MIDDLE name?
 
250 characters remaining "" 
6. What is your MAIDEN name? (enter n/a if applicable)
 
250 characters remaining "" 
7. What is your LAST name?
 
250 characters remaining "" 
8. Street address? (include apartment if appropriate)
 
250 characters remaining "" 
9. City
 
250 characters remaining "" 
10. State
 
250 characters remaining "" 
11. Please answer the following questions regarding religion.
 
Religion Please provide answers to these religious questions.
What is your religion?:  
Are you currently practicing your religion?:  
Do you have a religious limitation to your interest in being a surrogate?:  
If so, please describe:  
12. Zip Code
 
250 characters remaining "" 
13. What is your SPOUSE or PARTNER's FIRST name? (enter n/a if no spouse or partner)
 
250 characters remaining "" 
14. What is your primary phone number you want us to use for contacting you?
 
250 characters remaining "" 
15. Is your primary phone "text friendly" and may we text you for surrogacy reasons only?
 
"" 
16. What is your SPOUSE or PARTNER's MIDDLE name (enter n/a if no spouse or partner)
 
250 characters remaining "" 
17. What is your SPOUSE or PARTNER's LAST name (enter n/a if no spouse or partner)
 
250 characters remaining "" 
18. What are your OTHER phone numbers for contacting you?
 
Other Phone Phone Number May we leave a message
Home:    
Cell:    
Work:    
Other:    
19. What is your current maritial status?
 
"" 
If married or divorced, how long?
20. What is your spouse or partner's social security number? (reminder, you are on a secure server ... enter n/a if no spouse or partner)
 
250 characters remaining "" 
21. Date of Birth
 
   
22. What is your height?
 
"" 
23. What is your weight?
 
"" 
24. What race would you most likely be affiliated?
 
"" 
Please Explain
25. How many pregnancies have you had?
 
"" 
26. How many children have you given birth to?
 
"" 
27. What is your highest level of completed education?
 
"" 
28. Are you currently receiving any local, state, or federal aid including food stamps?
 
"" 
If Yes, Please Explain
29. Do you currently smoke cigarettes?
 
"" 
30. Do you live in a smoke free environment?
 
"" 
If no, please explain
31. Do you drink alcoholic beverages?
 
"" 
32. Are your currently breastfeeding?
 
"" 
33. Why do you want to become a surrogate?
 
250 characters remaining "" 
34. Are there any genetic diseases that run in your family? If so, please explain.
 
"" 
If yes, please explain.
35. Are you willing to adminster self injectable medications?
 
"" 
36. What is your current occupation and who is your current employer?
 
250 characters remaining "" 
37. Is your work schedule flexible?
 
"" 
38. In the past 12 months, have you had sex with a man who has had sex with another man in the past 5 years?
 
"" 
Please Explain
39. Have you injected drugs for a non-medical reason in the last 5 years, including intravenous, intramuscular, or subcutaneous injection?
 
"" 
Please Explain
40. Do you have a clotting disorder for which you have received human-derived clotting factor concentration?
 
"" 
Please Explain
41. Have you had sex for drugs or money in the past 5 years?
 
"" 
Please Explain
42. Have you had sex in the past 12 months, with anyone who would have answer "yes" to the above 4 questions?
 
"" 
Please Explain
43. In the past 12 months, have you had sex with a person known or suspected to have HIV, or active hepatitis B or C?
 
"" 
Please Explain
44. In the past 12 months, have you been exposed to known or suspected HIV, hepatitis B, and/or hepatitis C infected blood through percutaneous inoculation, contact with an open wound, non-intact skin, or mucous membrane?
 
"" 
Please Explain
45. In the past 12 months, have you been in jail for more than 3 days in a row?
 
"" 
Please Explain
46. In the past 12 months, have you been in close contact (i.e. sharing kitchen and bathroom) with a person having active viral hepatitis?
 
"" 
Please Explain
47. What compensation range are you seeking?
 
"" 
48. Have you ever been a successful surrogate carrier before?
 
"" 
49. Are you currently under agreement with another agency, family, attorney, or fertility group to be a surrogate?
 
"" 
50. Have you applied or ever been screened to be a surrogate?
 
"" 
If so, when and where?
51. What kind of surrogate program are applying?
 
"" 
52. If a family were willing to pay for your travel, are you willing and able to to drive up to 4 hours?
 
"" 
53. If a family were willing to pay for your travel, would you be willing to fly to the fertility center and have up to 4 overnights?
 
"" 
54. What is your closest major metropolitan area?
 
"" 
55. In consideration of using limited marketing resources, please let us know how you found this application?
 
250 characters remaining "" 
56. What resources have influenced your decision to apply?
 









Please provide which website, radio station, newspaper or person who referred you.
57. What is your email address for communication with you regarding your pre-screen application?
   
58. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
59. Verify your password.
   

Please add no-reply@donorapplication.com to your email contact list to prevent our response from being flagged as spam.