Adoption application.

Family name:  _________, Address: _________, County: _________, Home telephone _________, Rent _________, Own _________, Monthly payments _________, Mortgage value _________, Number of rooms _________, Number of bedrooms _________.

Others in household:

Name _________ Relationship _________ Age _________.

Name _________ Relationship _________ Age _________.

Marriage date: _________, Location: _________, License number _________.

Have you, as a married couple, ever applied to adopt a child through another source? Yes _________ No _________. If yes, where did you apply? _________. Date applied _________ Status _________.

Information pertaining to husband:

Name: First _________, Middle _________, Last _________.

Birth date _________, Birth place _________, Race _________.

Nationality _________, Citizenship _________, Religion _________.

Physical description: Height _________, Weight _________, Hair color _________, Eye color _________, Complexion _________.

Education:	Name and location of high school _________.
	Date and grade of high school completed _________.

 

Same information for any college _________, Degree _________.

Employment: Company name _________, Address _________, Telephone number _________, Date begun _________, Annual salary _________, Work hours _________, Position title _________, Type of work _________, Social Security number _________.

If you were in the Armed Forces, please give A.F. number _________.

Were you ever previously married? Yes _________, No _________, When _________, Where _________, Former spouse's name _________, Date marriage terminated _________, Where _________, By: Divorce? _________, Who filed? _________, Death? _________.

Information pertaining to wife:

Name: First _________, Middle _________, Last _________.

Maiden name _________, Previous married names _________.

Birth date _________, Birth place _________, Race _________.

Nationality _________, Citizenship _________, Religion _________.

Physical description: Height _________, Weight _________, Hair color _________, Eye color _________, Complexion _________.

Education:	Name and location of high school _________.
	Date and grade of high school completed _________.

 

Same information for any college _________, Degree _________.

Employment: Company name _________, Address _________, Telephone number _________, Date begun _________, Annual salary _________, Work hours _________, Position title _________, Type of work _________, Social Security number _________, A.F. number _________.

Were you ever previously married? Yes _________, No _________, When _________, Where? _________, Former spouse's name _________, Date marriage terminated _________, Where _________, By: Divorce? _________, Who filed _________, Death? _________.

Financial information:

Please attach a separate page listing stocks, bonds interest from savings or any other income or assets (please be specific with names and amounts), all debts and liabilities, all insurance policies (please give company name, what type of insurance, who is insured, amounts of coverage and name of beneficiary).

Emergency contact: Name _________, Relationship _________, Address _________, Telephone numbers (Day) _________(Evening), _________.

Please attach to your application, a recent photograph of family members: Husband, Wife, Child or Children (Polaroid photographs are acceptable).