Becoming a Sperm Donor

To see if you qualify, please complete the following application:

Origin is a licensed Canadian Sperm Bank. We provide frozen donor semen specimens to physicians for use in fertility treatments across Canada.

Recent statistics indicate that 15% of couples experience infertility problems. For many of these cases, the use of donor sperm represents a line of therapy. Since the early 1980's, the clinical practice of using donated sperm has become more prevalent. More and more physicians are seeking cryopreserved donor semen specimens since frozen specimens are able to be quarantined and donors are screened to ensure specimens are free from transmittable infectious diseases.

Complete the on-line application today to help make a difference!

Name *

Email *

Telephone *

Date of Birth *

Day 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

Month 1 2 3 4 5 6 7 8 9 10 11 12

Year 1944 1945 1946 1947 1948 1949 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 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Address *

City *

Province *

- - - Select region - - - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Postal Code/Zip *

Preferred method of contact: *

E-mail

Phone

Text Message

Are you or either of your parents adopted? *

Yes No

Have you had sex with a man in the preceding 3 months? *

Yes No

Have you used intranasal cocaine in the preceding 12 months? *

Yes No

Have you had a sexually transmitted disease in the preceding 12 months? *

Yes No

Security code (enter only the digits in the shaded area)