Donor Application

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:

1. Complete the application and the brief medical questionnaire.
2. Provide us with a short biography about yourself, your family, the level of education you have achieved, your professional career etc...
3. 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 whether you want to participate in New Jersey or New York office, as well as whether you want to join the "Anonymous" donor program or the "OPEN IDentification" 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 AFFILIATE: The Sperm Bank of New York, Inc. 1090 AMSTERDAM AVENUE, 7G NEW YORK, NY 10025 212-531-0115

DONOR PROFILE INFORMATION RACE:   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 NAME: TODAY’S DATE: Which program are you considering:     ANONYMOUS DONOR PROGRAM   OPEN Identification 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 year, 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 alcoholic 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 FULL NAME: ADDRESS: CITY:  Zip BIRTH DATE: E-MAIL:      PHONE (H): PHONE (W): CELL PHONE: If you hold a valid drivers license please complete item below. DRIVERS LICENSE NUMBER: State: