Apply to Be An Egg Donor Step-2

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Name
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Do you drink more than once a week?
Have you smoked cigarettes in the past 3 months?
Are you willing to take a nicotine screening test?
Have you completed high school?
Are you currently a college student?
Are you adopted?
Number of siblings
Do you have a college degree?
Have you ever had an abnormal pap smear?
I understand that a current pap (within 6 months) is required and that Simple Steps Fertility will be asking to receive a copy of my most recent pap results.
Have you or your partner tested positive for Chlamydia in the past 24 months?
Have you or your partner tested positive for Gonorrhea in the past 24 months?
Have you or your partner tested positive for Syphillis in the past 24 months?
Have you ever been incarcerated?
Are you willing to take a drug test?
Are you currently pregnant or breast feeding?
Have you received a tattoo in the past 12 months?
Have you traveled to a country in the past 24 months where you were advised / required to receive a malaria vaccine?
Have you lived in or visited any of the following countries for 3 or more months between 1980 and 1996? * Channel Islands, England, Falkland Islands, Gibraltar, Isle of Man, Northern Ireland, Scotland or Wales
Have you lived in any of the following countries for 5 or more consecutive years? Albania, Austria, Belgium, Bosnia / Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Kosovo (Federal Republic of Yugoslavia), Liechtenstein, Luxembourg, Macedonia, Montenegro (Federal Republic of Yugoslavia), Netherlands (Holland), Norway, Poland Portugal, Romania, Serbia (Federal Republic of Yugoslavia), Slovak Republic (Slovakia), Slovenia, Spain, Sweden, Switzerland, Turkey, Yugoslavia (Federal Republic includes Kosovo, Montenegro, and Serbia)?
Are you or any of your biological family members registered with any Native American tribes?
Are you currently enlisted in the Military?
Email us a recent photograph of yourself. Applications with photographs submitted will be processed faster.
Consent*
Name