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Preliminary Application

Please fill out the application below. Give detailed descriptions where appropriate. Upon completion of the application hit send. One of our team members will respond to you within a week by email or telephone. Please note you must be between the ages of 21 and 33 and live in New York City or the surrounding area (NJ, NY, CT suburbs).

Basic Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
Country:
* Email:
* Email again for verification purposes:
* Telephone 1:
Telephone 2:

Additional Information
* Date of Birth:
* Place of Birth:
* Height:
* Weight:
* Hair Color:
* Eye Color:
* Race:
* Ethnic Origin:
* Are you eligible to work in the US?	Yes No
* Occupation:
* What is your highest level of education?
* Where did you see our advertisement?

Medical Information
* Are your periods regular?	Yes No
* Have you ever been pregnant?	Yes No
If so, when and what was the outcome?
* Have you ever had a sexually transmitted disease?	Yes No
If so, what and when?
* Have you ever used any kind of recreational drugs such as marijuana, LSD, heroin, ecstasy, or cocaine?	Yes No
If so, please give details and date last used:
* Are you currently taking any medications?	Yes No
If so, what type?
* List medications taken in the last five years:
* Have you ever had surgery?	Yes No
If so, describe type and when:
* Do you have any illnesses?	Yes No
If so, describe:
* Do you or any of your family members have a history of cancer?	Yes No
If so, who and what type?
* Do you have a history of birth defects in your family?	Yes No
If so, who and what?
* Have you acquired a tattoo or other skin piercing within the last 12 months?	Yes No
If so, when?
* Have you lived outside the US?	Yes No
* If so, where and when?
* Please provide any additional information you find relevant:
	* Required