Home Recipient Information Donor Information Products Online Payments Testimonials Contact Us Recipient Application Donor Application Request a Call The Fertility Centre Frequently Asked Questions   Search Fertility 1st This website The web	DONOR APPLICATION REQUEST *  First Name:  * Surname:  * Occupation:  * Date of Birth Choose.. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Choose.. January February March April May June July August September October November December Choose.. 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 * Contact Email address:    nb. Only valid email addresses will result in registrations * Address:  Please give details * Postcode:  * Do You Smoke? No      Yes * If so how many per day? * Do you drink alcohol? No      Yes * If so how, many units per week? * Contact Phone Number * Contact Mobile Number * Sexual Preference Choose.. Heterosexual Gay Bisexual * Marital Status Choose.. Single Partnered Married Separated Divorced * Ethnic Origin Choose.. American Indian Asian Asian Bangladeshi Asian Chinese Asian Indian Asian Pakistani Australian Aboriginal Black Black African Black Caribbean Hispanic Mixed Oriental Pacific Islander White * Country of birth Choose.. Afghanistan Albania Algeria Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Ashmore and Cartier Islands Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Bassas Da India Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Coral Sea Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Europa Island Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern and A. Lands Gabon Gambia Gaza Strip Georgia Germany Ghana Gibraltar Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle Of Man Israel Italy Jamaica Jan Mayen Japan Jersey Jordan Juan De Nova Island Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue No Man's Land Norfolk Island North Korea Norway Oceans Oman Pakistan Palau Panama Papua New Guinea Paracel Islands Paraguay Peru Philippines Pitcairn Islands Poland Portugal Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia & S.S.I. South Korea Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tromelin Island Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands Wallis and Futuna West Bank Western Sahara Yemen Zambia Zimbabwe * Hair Colour Choose.. Black Dark Brown Medium Brown Light Brown Lightest Brown Auburn Blonde (All Shades) Red (All Shades except Auburn) Grey Black Donors * Eye Colour Choose.. Black Dark Brown Light Brown Blue Green Grey Hazel Black Donors Please check your answers to weight and height – incorrect responses here will vastly reduce your selection chances. * Height Choose.. 4ft 0in / 122cm 4ft 1in / 125cm 4ft 2in / 127cm 4ft 3in / 130cm 4ft 4in / 132cm 4ft 5in / 135cm 4ft 6in / 137cm 4ft 7in / 140cm 4ft 8in / 142cm 4ft 9in / 145cm 4ft 10in / 147cm 4ft 11in / 149cm 5ft 0in / 152cm 5ft 1in / 155cm 5ft 2in / 158cm 5ft 3in / 160cm 5ft 4in / 162cm 5ft 5in / 165cm 5ft 6in / 168cm 5ft 7in / 170cm 5ft 8in / 172cm 5ft 9in / 175cm 5ft 10in / 178cm 5ft 11in / 180cm 6ft 0in / 183cm 6ft 1in / 185cm 6ft 2in / 188cm 6ft 3in / 190cm 6ft 4in / 193cm 6ft 5in / 195cm 6ft 6in / 198cm 6ft 7in / 200cm 6ft 8in / 203cm 6ft 9in / 205cm 6ft 10in / 208cm 6ft 11in / 210cm 7ft 0in / 213cm * Weight Stones Kilograms * Any history of multiple births? No      Yes Identical? No      Yes * Are you one of a multiple birth? No      Yes * Blood Group Choose.. O+ A+ B+ AB+ Rh- Unknown Have you or any member of your family, ever been dignosed with any of the following conditions? * Cancer No      Yes * Diabetes No      Yes * Heart Disease No      Yes * Alcoholism No      Yes * Arthritis including gout rheumatoid No      Yes * Asthma No      Yes * Autism No      Yes * Auto-immune disease No      Yes * Congenital hip disease No      Yes * Cystic fibrosis No      Yes * Deafness No      Yes If answered yes then please elaborate Please give details * Down Syndrome No      Yes * Epilepsy No      Yes * Dyslexia No      Yes * Blindness and cataracts No      Yes * Kidney Disorders No      Yes Malformations, including Have you or any member of your family, ever been dignosed with any of the following conditions? * Cleft Palate No      Yes * Dwarfism No      Yes * Club foot No      Yes Mental Illness, including Have you or any member of your family, ever been dignosed with any of the following conditions? * Depression No      Yes * Schizophrenia No      Yes * Manic depressive psychosis: No      Yes * Retardation No      Yes * Sickle cell anaemia No      Yes * Thyroid disorder No      Yes * Any personal history of STD's No      Yes If so, please give details... Please give details If you have answered yes to any of the above medical questions please enter any details here   Please give details * Have you ever fathered children? No      Yes If so, how many Choose.. 1 2 3 4 5 More than 5 If so, what age/s   If so, what sex/es Choose.. M F Choose.. M F Choose.. M F Choose.. M F Choose.. M F   Any child conceived from your donations may request details of the donor when he/she becomes 18 years of age. Is this acceptable? No      Yes Extra Information * Brief note as to why you want to register as a donor Please give details * Brief history of yourself and family history Please give details * Brief history of your education, achievments & qualifications. Please give details * What are your hobbies and interests Please give details What is your religion * Would you allow Fertility1st to give your details to women who wish direct contact with a donor to arrange their own fresh sperm donations. You would need to negotiate expenses with the recipient. If you choose yes to this option we will call you to discuss this further. No      Yes * Would you consider being a frozen sperm donor with the understanding that the child has the right to find your details when they become 18 years of age. You are in no way financially responsible for any children born resulting from frozen sperm donation. If you choose yes to this option we will call you to discuss this further. No      Yes I confirm that I have read and understood the terms and conditions for Fertility 1st products and services and agree to be bound by them. I acknowledge that I am over 18 years of age, and that the answers to my questions within this questionnaire are to the best of my knowledge true and accurate. Further I understand that Fertility 1st Limited will retain my details on file for the purposes of providing certain information to appropriate recipients, will not be held responsible for any actions as a result of the dissemination of my information and finally that I have the control to amend or remove my details at any time. Please tick to confirm you have read and understood our terms and conditions * = Required field.
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