Egg Donor Application Egg Donor Application Take the first step towards giving an incredible gift Name* First Middle Last Maiden Name Email* Enter Email Confirm Email What City & State do you reside?* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Are you between the ages of 20 – 28?*YesNoIs your BMI below 30?*You can use this BMI calculatorYesNoDo you smoke or use tobacco in any form?*YesNoAre you currently taking any anti-depressants or anxiety medications?*YesNoCan you obtain accurate, up-to-date health information on your biological parents, grandparents and siblings?*YesNoHave you ever been diagnosed with ADD/ADHD or any other type of learning disability?*YesNoHave you ever tested positive for the HIV virus, HTLV infection, Hepatitis B virus or Hepatitis C virus?*YesNoIn the past 12 months have you undergone tattooing, ear piercing or body piercing?*YesNoIn the past 12 months have you been treated for or had Syphilis, Chlamydia, or Gonorrhea?*YesNoHave you traveled outside of the US in the past 12 months?*YesNoHave you ever been or applied to be an egg donor before?Yes, I've applied, was accepted and donated beforeYes, I've applied, was accepted but never donatedYes, I've applied but was deniedNo, I've never applied beforeHow many times have you donated before?1 time2 times3 times4 times5 timesMore than 5 timesHave you applied or been screened to be an egg donor with other agencies?YesNoWhich clinic(s) and location(s)?*How did you hear about us?*CraigslistGoogleFacebookFriendMagazineEggDonorAgency.netWho did you get referred by?*What magazine?*Your Personal DetailsName* First Middle Last Maiden Name Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of birth* Date Format: MM slash DD slash YYYY Cell Phone Number:*Home Phone Number:Work Phone Number:Who is your emergency contact?*Please provide a contact who is not living with you. First Last Home or Cell Phone Number:*Health Insurance Carrier:Your Family & Living SituationWhat is your marital status?*MarriedEngagedRelationship (co-habitating)Relationship (living separately)SingleDivorced (finalized)Divorced (in process)Legally SeparatedSeparated (non-legal)WidowedWhat is your spouse/partner's name?* First Middle Last What's your spouse/partner's date of birth?* Date Format: MM slash DD slash YYYY Spouse/Partner's Driver’s License Number:Issuing State:Will you have emotional support from someone close to you?*YesNoWhat relationship is this person to you?*Does this person live with you?*YesNoWith whom have you discussed your intentions about becoming an egg donor and what was their reaction?*Did you consult with your family when completing your Family Medical history?*YesNoYour CharacteristicsWhat is your height?*What is your weight?*What is your blood type?*A+A-B+B-AB+AB-O+O-I don't knowWhat is your Body Mass Index (BMI)?*You can use this BMI calculatorWhat is your race?*What is your ethnic background?*American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinaNative Hawaiian or Other Pacific IslanderWhiteEthnicity father:*American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteEthnicity mother:*American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinaNative Hawaiian or Other Pacific IslanderWhiteEthnicity maternal grandfather:*American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteEthnicity grandfather:*American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteEthnicity maternal grandmother:*American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinaNative Hawaiian or Other Pacific IslanderWhiteEthnicity grandmother:*American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinaNative Hawaiian or Other Pacific IslanderWhiteAre you religiously affiliated?*YesNoWhat is your current religious affiliation?*Physical build:*PetiteSmallMediumLargeEye color:*Natural hair color:*Current hair color:*Natural hair texture:*Hair thickness:*Complexion:*Very fairFairTanLight oliveOliveDark OliveBrownBlackDominate hand:*Right-handedLeft-handedAmbidextrousDimples:*YesNoAre you adopted?*YesNoDo you know your medical history?*YesNoPlease provide a description for each parent and grandparent:*Mother, Father, Grandmother (mom's side), Grandmother (dad's side), Grandfather (mom's side), Grandfather (dad's side)RelativeRaceHeightWeightPhysical build Do you smoke?*YesNoHave you ever smoked?*YesNoDo you drink alcohol?*YesNoHow often?*Have you used illegal drugs?*YesNoWould you agree to take a drug test?*YesNoTattoos & Piercings (month & year):Describe any special talents, skills or abilities that you have (artistic, athletic, intellectual, other):*What size pants do you wear?*Size tops?*Shoe size*Bra size:*Dress size:*What is your favorite clothing?*Describe how you look:*How athletic are you?*Not athleticAverageVeryWhat types of exercises or physical activities do you do?*What do you like doing in your spare time?*What do you like most about yourself?*If you could change one thing in the world what would it be and why?*What is important and what do you value most in life?*Employment & EducationCurrent occupation:*Hours:Full timePart timeTypical weekly work schedule – days and times:Year completed High School:Grade average:Received GED:Currently in college, pursuing degree in:GPA:Completed college, degree in:GPA:Name of Colleges attended or attending:Attending Technical or Business School?*YesNoCompleted Technical or Business School program?*YesNoTitle of Degree and Year received*Academic Strengths (i.e. math, reading):Musical Talent or Instrument?Artistic Talent?Do you speak a language other than English?*YesNoWhat languages?*Athletic/Sport Skills?Your Health HistoryAge at first period:*Are your periods regular?*YesNoAny treatments needed for menstrual problems?*YesNoPlease describe:*Have you ever had trouble becoming pregnant?*YesNoNumber of sex partners within the last 6 months:*Has your sex partner had other sex partners in the last 6 months?*YesNoNot applicableHave you ever had an HIV screening completed?*YesNoPlease give results and year:*Have you had any history of abnormal PAP Smears?*YesNoPlease give results and date last pap smear completed:*Are you using birth control?*YesNoWhat form(s) of birth control are you currently using?* Birth Control Pills NuvaRing Diaphram Patch Implanon/Nexplanon Tubal Ligation Partner Vasectomy Condoms IUD Essure Depo Shot How long have you used this form of birth control?*Your Pregnancy HistoryPregnancies:YearC-Section/VaginalMiscarriageTerminationOtherHealthy baby Did you have any complications during these pregnancies?YesNoPlease describe:*Children:Boy/GirlDOBSexAgeChild lives with? Were the children healthy at birth?YesNoPlease describe:*Have you had any surgery or medical procedure?*YesNoPlease list the year and treatment:*YearTreatment Have you ever been in counseling or psychotherapy?*YesNoPlease describe:*Are there twins in your family?*YesNoWhich side of the family & generation?*Your Family Genetic HistoryPredominant family hair color:*Predominant family eye color:*Predominant family stature:*ShortAverageTallPredominant size:*Petite/SmallAverageLargeX-largePredominant family trait (physical)*Ex: tall, big eyesFamily personality traits:*Family traits for sports:*Family traits for music:*Family traits for education/school:*Family intellectual traits:*Family traits for technical/manual skills:*Have twins or multiple births occurred in your family?*YesNoHow would you rate the longevity of age in your family?*Are there any traits that are common in your family?*Is there anything that is very typical in your family?*Please provide a photo of you:This should include at least one headshot and one full body picture. Drop files here or If there's anything you would like to add to your application, feel free to do so here: