BioGenetics™ Corporation

BioGenetics Corporation

Providing Donors of Diverse Ethnic Origins Worldwide with Assured Personal and Confidential Care

Donor Application

Thank you for your interest in considering becoming a sperm donor.

Please read thru the pertinent information about our program entitled, "Becoming an Exclusive Donor". To proceed with the application process, you will need to follow these instructions.

The following items MUST be submitted all together for evaluation purpose:
All three (3) must be submitted to be considered.

Complete the application and the brief medical questionnaire.
Provide us with a short biography about yourself, your family, the level of education you have achieved, your professional career etc...
Submit a recent digital or print photo of yourself.

Once we have had the opportunity to review your information we may write or call you to schedule an appointment for an interview and possibly have you collect your first sample to start the process of evaluating your potential to becoming a sperm donor for our program.

PS: check off as to whether you want to join the "Anonymous" donor program, "Access" donor program or the "Total Access ID" ™ (T.A.ID) Donor program.

You can complete the documents "on line" and submit via secured e-mail to director@sperm1.com or you can down load the application kit and mail the complete kit to the land address:


HEADQUARTERS: BioGenetics Corporation 187 MILL LANE MOUNTAINSIDE, NJ 07092 908-654-8836 / 800-637-7776

DONOR PROFILE INFORMATION

RACE:

OTHER

CAUCASIAN

BLACK

ASIAN

ETHNIC ORIGIN<Ancestry>MOTHER’S FAMILY:
ETHNIC ORIGIN<Ancestry>FATHER’S FAMILY:
RELIGION:

SKIN TONE:	FAIR	MEDIUM	DARK
HAIR COLOR:	BLACK	BROWN	RED	BLONDE	AUBURN
HAIR TEXTURE:	STRAIGHT	CURLY	WAVY	KINKY
EYE COLOR:	BROWN	GREEN	BLUE	HAZEL

HEIGHT:	FT	IN	WEIGHT: LBS
FRAME SIZE:	SMALL	MEDIUM	LARGE

EDUCATION: # OF YEARS COMPLETED (including high school):
Do you hold a degree from an accredidated University or College:	Yes	No
What type of degree(s) do you hold?

MARITAL STATUS:

SINGLE

MARRIED

DIVORCED

OCCUPATION:
INTEREST/HOBBIES:

PERSONAL QUESTIONNAIRE

FIRST NAME:

TODAY’S DATE:

Which program are you considering:
	OPEN "TOTAL ACCESS DONOR PROGRAM
Which site will be convenient for you?		NJ NY

What is your current occupation?

Have you changed jobs in the last year and for what reason?

How may years of college have you completed?

Are you still attending college?

What is your major?

Have you traveled outside of the US in the past six months, if so where?

What is your marital status?

Has it changed in the past year?

Yes

No

How many children do you have?	If yes, What sex and age?

Have you been seen by Doctor in the past year?	If yes, for what reason.

Have you had any type of surgery or been hospitalized in the last 12 months? If yes, please explain:

Have you received any blood transfusions, blood products, or intravenous injections in the past 12 months?

Yes

NO

Have you had major radiation exposure or X-ray exposure in the last 12 months?

Yes

NO

Has anyone in your immediate family been hospitalized or under a doctor’s care, other than for routine physical check-ups in the last 12 months? If yes, please explain

Have you ever donated blood or plasma in the last 12 months? If yes, When?

Have you ever been rejected as a blood donor in the last 12 months?

Were you ever a sperm donor : Yes No

Do you currently have any allergies?

If yes, are they due to: Food Drugs Environmental Other

How is your vision? Very good Good Poor

Do you wear glasses or contacts? Yes No

Do you have normal hearing? Yes No

Condition of your teeth: Poor Fair Good Excellent
Your diet is: Vegetarian Non-vegetarian

Do you drink alcohol beverages? What kind and how often?

Do you smoke cigarettes, cigars, pipes or use any tobacco product?
If yes, how often?

How many sexual partners have you had in the last six months?

Of what gender were your sexual partner(s)? Female(s) Male(s) or from both sexes

Have you or any of your sexual partners contracted or been diagnosed with any sexually diseases within the last twelve months? Yes No what type?

Have you been arrested or incarcerated in the past year?
If yes, please explain

In the past year have you experimented or used any recreational drugs?

In the past year have you taken any prescription medication and what kind?

Have you been tattooed in the last 12 months? Yes No

Have you undergone a body piercing procedure in the last 12 months? Yes No

If so, what part of your body is pierced?

PERSONAL DEMOGRAPHICS

FIRST NAME:

BIRTH YEAR:

E-MAIL:

How old were you on your last birthday?.

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