Personal Information:

Husband’s Legal Full Name:

Age: DOB: (mm/dd/yyyy)   SSN:

Wife’s Legal Full Name:

Age: DOB: (mm/dd/yyyy)   SSN:

Street Address: Town/City:

State: Zip Code: Home Telephone:

E-mail: FedEx Acct#:

Employment Information:

Husband’s Employer:

Title: Annual Income: $

Years with company: Telephone: Ext.:

Wife’s Employer:

Title: Annual Income: $

Years with company: Telephone: Ext.:

Please answer the following questions:

Do you have criminal history, including DWI records? Yes No

Do you have any life threatening or chronic illness? Yes No

If you answered “yes” to questions 1 or 2, insert explanation on a below. All information is confidential (privacy policy) .

Please specify the age and gender of the child you desire to adopt.

Would you consider adopting a child with special needs? Yes No

Please add any comments or concerns you may have regarding the child you wish to adopt.

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