1.

What is your FIRST name? *

2.

What is your LAST name? *

3.

This will require travel. How far are you from the Fort lauderdale area? *

4.

What is the primary phone number (include area code) to use for contact and leaving messages? *

5.

Are you eligible to work in the United States? *

6.

Are you a US citizen or permanent resident? *

7.

What is your date of birth? *

8.

What race would you most likely be affiliated? *

9.

Are you adopted? *

10.

What is your height? *

11.

What is your weight? *

12.

Is your work schedule flexible? *

13.

Do you have both ovaries? *

14.

Are your periods regular when you are not on any type of hormonal birth control such as the pill, etc.? *

15.

Are your currently breastfeeding? *

16.

Have you ever been told you were infertile? *

17.

Do you currently smoke cigarettes? *

18.

How many cigarettes do you smoke per day? *

19.

How many drinks do you usually consume in a week? *

20.

Have you ever used recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)? *

21.

Have you ever used medications such as antianxiety or antidepressants to treat an emotional or psychological problem? *

22.

Have you ever taken anti-malarial drugs or had malaria? *

23.

Have you had acupuncture, ear and/or body piercings or tattooing on your body? *

24.

Have you had a blood transfusion? *

25.

Have you ever been refused or denied as a blood donor? *

26.

Have you spent 3 months or more cumulative in the United Kingdom from 1980 through 1996? *

27.

From 1980 through 1990, were you a member of the US military, a civilian military employee or a dependent of a member of the US military, residing in US military bases in Northern Europe (Germany, Belgium and the Netherlands) for 6 months or more, or elsewhere in Europe (Greece, Turkey, Spain, Portugal, Italy) for 6 months or more from 1980 through 1996? *

28.

Have you spent 5 or more years cumulative in Europe? *

29.

Have you applied or been screened to be an egg donor before? *

30.

Are you currently enrolled as an egg donor in another program? *

31.

How many times have you donated? *

32.

What is/are your reasons for wanting to donate eggs? *

33.

What resources have influenced your decision to apply? *


What is your email address for communication with you regarding your pre-screen application?
(6-20 characters with 4 or more letters and 1 or more numbers)
(Must match)