1. Are you eligible to work in the United States?
 
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2. What is your FIRST name?
 
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3. What is your LAST name?
 
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4. What is your address?
 
---> Street Address Apartment No. City State Zip Code Country
::            
5. Approximately how far away do you live from Milwaukee?
 
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6. Please provide your phone contact information. (Leave the Phone Number column blank if you do not want a call there).
 
----> Phone Number Ok to leave message? Best Time of Day
Cell Phone:      
Home Phone:      
Work Phone:      
7. What is your current occupation?
 
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8. What is your date of birth?
 
   
Please Explain
9. What is your current height? Your height will be verified for accuracy.
 
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10. What is your current weight? Your weight will be verified for accuracy.
 
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11. What is your race as most people would identify you?
 
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Please Explain
12. What is your highest level of completed education?
 
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13. Are you adopted?
 
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14. Do you smoke?
 
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Please Explain
15. Have you ever smoked?
 
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Please Explain
16. Are your periods regular?
 
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Please Explain
17. Have you ever taken the following drugs / agents?
 
Drugs / Agents Details Date Last Used
Marijuana:    
LSD:    
Heroin:    
Cocaine:    
Other mind altering drugs:    
Tranquilizers:    
Valium:    
Thorazine:    
Other neuroleptic agents:    
18. Have you ever been pregnant?
 
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19. Have you ever had inpatient treatment for mental health issues?
 
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Please Explain
20. How many times have you been an egg donor? (Please provide the date of any previous egg donation).
 
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Please Explain
21. How did you hear about us?
 
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22. What is your email address for communication with you regarding your pre-screen application?
   
23. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
24. Verify your password.
   

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