Pacific Reproductive Services
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Donor Initial Application

Please fill out the following form to be considered for donation. All form fields are required. Note: If emailing this form, we cannot guarantee the security of your information. If web security is a concern to you, please print our PDF form and fax it to us.

Part I: Personal Information

Please indicate your personal and contact information:

First Name:
Last Name:
Mobile Phone No.:
Home Phone No.:
Work Phone No.:
Email Address:
(PRS will contact you via this email address)
Best Time To Contact You:
Address (No P.O. Boxes):
Apt. No. (if applicable):
Zip Code:
Ethnic Background (Mother):
Ethnic Background (Father):
Height (Ft/In):
Weight (Lbs):
Date of Birth (Month/Year): /
Are you currently enrolled in or applying to school? Yes     No
Do you have any special training or certifications? (max 50 char.)
Profession: (max 50 char.)
Employment Status:
Are you a U.S. citizen? Yes     No
Are you currently in the military, active duty or reserve? Yes     No
To which office are you applying?

Part II: Medical History

Do you or anyone in your family have a history of:

Heart Disease: Yes     No
Diabetes: Yes     No
Birth Defects: Yes     No
Genetic Conditions: Yes     No
Cancer: Yes     No
Mental Illness: Yes     No
Alcoholism/Substance Abuse: Yes     No
Do you drink alcohol? Yes     No
Do you smoke cigarettes? Yes     No
Do you have access to your biological family's medical history? Yes    No
Are you able to make a one-year commitment? (donating on average once weekly?) Yes    No
Have you had oral or anal sex with another male in the past 5 years? Yes     No
How many sexual partners have
you had in the last
6 months:   
1 year:
Have you ever been a donor for a sperm bank? Yes     No
How long have you lived in the area? yrs, mo
How did you hear about us?

(Please only press submit once.)

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