Egg Donor Application

Welcome to the Egg Donor Application.
Thank you for your interest in the egg donor program.

Please note that all answers are verifiable with medical testing required during the screening process.


First Name:
Last Name:
Email Address:
Confirm Email Address:
Do you live within two hours of our monitoring facilities located in Fairfax, VA or Towson, MD?  Yes   No
Date of Birth:
Height: ft. in.
Weight: lbs.
Your Parentage:  Natural child of parents  
 Donor Conceived  
What is your highest level of education?
Ethnic Background:
Smoker?  Yes   No
Have you ever been convicted of a felony?  Yes   No
Have you ever had sex with anyone in exchange for drugs or money, or has anyone you have had sex with done the same?  Yes   No
Have you ever had relations with someone suspected of HIV or viral hepatitis?  Yes   No
Have you or any of your family members been diagnosed with alcoholism or drug addiction?
Are you currently taking medications for any of the following conditions: Depression, Anxiety, ADD/ADHD, Bipolar?  Yes   No
Have you, in the past two years, used any of the following: Marijuana, Heroin, Cocaine, Barbiturates, or Amphetamines?  Yes   No
Have you spent 3 or more cumulative months in the UK from 1980 through 1996?  Yes   No
Have you lived for 6 months or more at U.S. military bases in Northern Europe (Germany, UK, Belgium Netherlands) from 1980 through 1990 or elsewhere in Europe (Greece, Turkey, Spain, Portugal, and Italy) from 1980 through 1996?  Yes   No
Have you spent a cumulative total period of 5 years or more in Europe from 1980 until the present?  Yes   No
Are you currently pregnant?  Yes   No
Are you currently breastfeeding?  Yes   No
How did you hear about our program?
OPTIONAL: We would like to be able to attract potential donors using the internet on sites that are popular with you and your peers. Please share your favorite websites:


Thank you for your interest and time.
We will contact you by email on the status of your application.