DONOR APPLICATION
 
 

Ron Harris, Inc.
D/b/a/ www.ronsangels.com
email cs@ronsangels.com
Fax no. at http://www.ronsangels.com/fax.html

NOTE: A copy of a suitable picture I.D., such as a driver's license, which shows your date of birth, must be submitted with this application.

PERSONAL

Name_________________________________________________________________________
    (Last)                                 (First)                         (Middle)

Address______________________________________________________________________
      (Street)                                 (City)                 (State)          (Zip code)

Telephone_______________Social Security Number____________Email____________
            (incl. Area Code)

Driver's License Number________________State_____Expiration Date___________

Ever convicted of a crime__yes__no If yes, explain_________________________

Are you a citizen of the United States__yes__no If no, country:____________

Your age:_____ Your race:________ DOB:_______ Place of birth:______________

Eye color:_____Hair color:_____Height:______Weight:_____Complexion:________

Measurements: Bust ___ _AA _A _B _C _D _ DD Waist:_______Hips:_______

Marital Status: ____________ Religion: __________

Ethnicity of Ancestors:____________________________________________________
 
 

For each relative, answer: Living?; Age or age of death; Health, or cause of death; Any genetic disorder(Tay-Sachs, etc)

Mother__________________________________________________________________________

Father__________________________________________________________________________

Maternal Grandmother____________________________________________________________

Maternal Grandfather____________________________________________________________

Paternal Grandmother____________________________________________________________

Paternal Grandfather____________________________________________________________

Siblings________________________________________________________________________
 
 

Have you ever smoked? _____ For how long? ______________________________________

Recreational drug use at any time? ________    If you prefer not to answer, checkhere _____

If you have children, give ages and health: ____________________________________

Your occupation or name of school: _____________________________________________

How would you describe your health? ____________________________________________

Please check if you might have interest in serving as a surrogate mother(carry a child to term

for a couple):_________

Currently we have customers bidding in the $350,000.00 range for an intelligent, healthy surrogate mother.

REASONS FOR SEEKING TO DONATE

Reason for donation:_______________________________________

Minumum acceptable price for donating  $__________________________

Have you ever been an egg donor before? __yes __no If yes, when?_______________

What was the result of the donation? ___________________________________________

Earliest date you could donate:_____Has your doctor approved your donation?:____

Are there any limitations on your ability to travel to recipient for donation?: ____________________________________________________________________

Other information you would like to provide or which you believe relevant: __________________________________________________________________________
 

EDUCATION
For each institution please answer:
Name and location; course of study; # of yrs; G.P.A.; Degree(s) and honors

High School_____________________________________________________________________

College/ University_____________________________________________________________

Other Education_________________________________________________________________

Other Special Academic

Achievement_____________________________________________________________________
 

SCHOLASTIC, ATHLETIC, AND ARTISTIC ABILITY

Scholastic Aptitude Test Scores: Verbal:____ Math:____ Achievement(subject and score)___________

GRE, LSAT, MCAT, GMAT, etc. Specify test and score:_____________________________

If you have ever taken an IQ test or tests, including the Miller Analogies Test:

Date_________

Full-scale score__________

By whom administered:___________________________________

Name of tests(WAIS, Stanford-Binet, WISC, etc.)_________________________________

Please describe any exceptional athletic, artistic or musical abilities or achievements:

______________________________________________________________________________________
 

OCCUPATIONAL RISKS/MEDICAL

Are you ever exposed to radiation or chemicals in your employment or school? If so, please explain:_____________________________________________________________

Have you ever been tested for HIV __yes __no

Dates, results_________________________

Cosmetic surgery at any time? __yes __no        Procedure(s)____________________

On any regular medications? __yes __no          Medications?____________________

Depressive or psychiatric disorder __yes __no   Diagnosis:______________________
 

YOUR AUTOBIOGRAPHICAL STATEMENT

This statement you write will appear on your web page on the donor site. The bidders do not initially see this application (they are not provided a copy without your permission although we may use selected information you have included on this application on your page or to respond to specific questions they may pose). Therefore your statement would do well to reiterate some or all of the information you have provided earlier in this form. It should cover your place of birth, where you were raised, any interesting aspects of your upbringing, your interests and achievements in high school and college, standardized test or IQ scores if you feel they are relevant, your employment prospects, aspirations, and your reasons for seeking to become a donor. Try to give a flavor of you personality in your response! If more room is needed, feel free to attach a separate sheet.
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SPECIAL NOTE REGARDING PHOTOGRAPHS: We need two clear photos submitted to www.ronsangels.com in support of this application, a close-up of your face and a full-length fashion shot. For the close-up, the pose should be looking directly into the camera smiling! The fashion shot should show your figure. Your photographs will present more suitably if you wear light to moderate makeup. Please be sure the background of your photographs is as neutral as possible, and that there is full, direct light on your face in both pictures. Natural outdoor light is best, but avoid shadows caused by excessively sharp sunlight, especially for the close-up. Photographs may be sent by email to cs@ronsangels.com or via the Postal Service to the address available at http://www.ronsangels.com/mailaddress.html. Please do not send photographs by fax. For the application itself, our fax number is here. (remember we also need the original by mail). Please include your email address on all faxes and with all correspondence!

ACKNOWLEDGEMENT

I certify that the answers given by me in this application are correct to the best of my knowledge. I understand that any falsification of this application, whether willing or accidental, is grounds for disqualification as a donor. I authorize you to investigate the accuracy of any statement made by me. Any of the information in this application or otherwise obtained by you, including any photographs, may be used to publicly promote my candidacy. I warrant that I have full publication rights to all photographs or images supplied. I acknowledge you are not responsible for misuse of these materials by others. I further represent that I have read the User Agreement published on the www, ronsangels.com website, as from time to time amended, and agree that it shall govern at all times, in addition to any other agreements I may execute, during my participation in the donor program. Some such agreements may be executed in, and subject to the status of, another jurisdiction, and may limit jurisdiction or venue of particular forums. I hereby irrevocably remise, release and indemnify Ron Harris, Ron Harris Inc. and any other successor(s) or affiliate(s), their officers, directors, agents, employees and independent contractors, including but not limited to any person or entity which I have had contact regarding the program, of and from all suits, claims, controversies, damages and the like occasioned by or flowing from either my participation in this program or the acts of any person or party herein released in furtherance of said participation.
 
 

Applicant’s Signature____________________________________________ Date__________