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Name of Adoptive Mother:_______________________________
Date and Place of Birth:_________________________________
Occupation:___________________________________________
Employer:____________________________________________
Work Phone:__________________________________________
Name of Adoptive Father:_______________________________
Date and Place of Birth:_________________________________
Occupation:___________________________________________
Employer:_____________________________________________
Work Phone:__________________________________________
Home Address:________________________________________
Home Phone;_______________Cell Phone:_________________
E-mail Address:________________________________________
Date and Place of Marriage:______________________________
Prior Marriages:_______________________________________
Others in Home:_______________________________________
Mother's Education:____________________________________
Father's Education:_____________________________________
Have you applied to another agency?___Which one?_________
Have you ever been turned down by another agency or country?______
Have you been named as a defendant in a criminal matter?____
Have you ever been accused of child abuse or neglect?____
Have you ever been a plaintiff or defendant in a civil suit?___
Have you ever had a problem, either as a victim or perpetrator with child abuse, domestic violence, mental illness, sexual abuse, drug and/or alcohol abuse?____
Please explain on another page if any answer is "yes"
Why do you believe that you are qualified to adopt a child?
What kind of direct experiences have you had with children?
Please use an additional page to provide this information.
Name of Placing Agency:________________________________
Desired age, race and sex of child:________________________
3 References with names and addresses:
____________________________________________________
__________________________________________________________________________________
____________________________________________________________________________________
________________________________________ ______________________________________
Patent Signature Parent Signature
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