Application

DONOR EGG BANK INC. - CONTACT/PERSONAL INFORMATION
Name:
Street Address:
City:	State:	Zip Code:
Email Address:

Home Phone:	Work Phone:	Cell Phone:
Best way to contact you and/or leave detailed message: (Please include specific contact information such as email address and/or phone number)
How did you hear about the Donor Egg Bank?:
Personal Information
Date of Birth:	Height:	Weight:
Eye Color:	Hair Color:	Complexion:
Race/Ethnicity: African American Asian CaucasianPacific Islander Hispanic/Latino Native American Other
Please describe your ethnic background (ie Italian, Irish, Spanish, etc.):
Religion/Spiritual Affiliation: Marital/Relationship Status:Married Single

ACADEMIC INFORMATION
GPA:	ACT Score:	SAT Score:
Other Scores (i.e. LSAT, MCAT, etc.—please specify tests and score):

EDUCATION INFORMATION

Highest level of education achieved:

Are you currently enrolled at any educational institution? Yes No

If yes, please list the school and what type of program you are enrolled in:

MEDICAL HISTORY/INFORMATION

Do you have any current medical problems? Yes No

If yes, please give details:

Are you currently taking any medications, herbs, or supplements? Yes No

If yes, please give details:

Does your family history include any significant medical problems? Yes No

If yes, please give details:

Do you or does anyone in your family have any emotional or mental disorder such as: Alzheimer's, bi-polar disorder, clinical depression or schizophrenia? Yes No

If yes, please give details:

Do you or does anyone in your family have a history of cancer? Yes No

If yes, please give details:

Does your family history include any genetic disorders such as: cystic fibrosis, sickle cell anemia, hemophilia or Tay Sachs disease? Yes No

If yes, please give details:

Do you have regular periods? Yes No

If no, please give details:

Are you currently sexually active? Yes No

Have you ever been sexually active? Yes No

If yes, when?

Have you are or sexual partner ever had (please check all that apply):

ChlamydiaGonorrheaHerpesVenereal WartsOther

If yes to any of the above, please give details:

Are you currently on any form of birth control? Yes No

If yes, what kind?:

Does your family history include any fertility problems? Yes No

If yes, please give details:

Have you ever donated your eggs in the past? Yes No

If yes, please give number of times and details:

Have you ever been pregnant? Yes No

Have you lived outside of the United States for more than 3 months since 1980? Yes No

If yes, please give details on where you lived, which year(s) you lived there and for how long:

PERSONAL PROFILE/STATEMENTS

Are you interested in? Frozen egg donation Traditional egg donation Both

Are you currently working? Yes No

If yes, what is your current occupation?

What are your career goals?

Do you have any special talents, skills, hobbies, or interests? Yes No

If yes, please give details:

How would you describe your personality and character?

What is your ultimate goal and ambition in life?

The Donor Egg Bank, Inc. serves a very diverse clientele. Are there any categories listed below that you would NOT be willing to donate your eggs to? (Please check all categories that apply)

Heterosexual CoupleHeterosexual Single FemaleHeterosexual Single MaleGay/Lesbian CoupleGay/Lesbian Single

PHOTOGRAPH
Please include a recent photograph (digital is preferred) with your pre-screening application. You may also send a digital photo under separate cover to info@donoreggbank.com or fax a photo to: 310.868.2933. Your application cannot be fully processed without a photo.