Adoption Advocates
11407 Seminole Blvd.
Largo, Fl. 33778
APPLICATION
Please print this document out (this document must be signed therefore it cannot
be processed electronically) and answer the following questions completely by
typing or printing and return to the address listed above. Please include a
non-refundable application fee of $250.00 and a family photo.
1. Name of Husband ______________________________________________
2. Date and Place of Birth ______________________________________
3. Husband's Social Security Number _____________________________
4. Name of Wife _________________________________________________
5. Wife's Date and Place of Birth _______________________________
6. Wife's Social Security Number ________________________________
7. Present Address ______________________________________________
8. How long have you lived there? _______________________________
9. Telephone (Home) ________________ (Work) _____________________
10. Previous Address _____________________________________________
11.How long did you live there? _________________________________
12.Present Marriage (When) ____________ (Where) _________________
13.Children of Present Marriage:
_________________________________________________________________
Name Age Natural or Adopted
14.Previous Marriages:
To Whom Where/When Ended
Husband _________________________________________________________
_________________________________________________________
Wife _________________________________________________________
_________________________________________________________
15.Children of Previous Marriage:
______________________________________________________________
Name Age Natural or Adopted
______________________________________________________________
Name Age Natural or Adopted
16.Personal Data:
Husband Wife
Citizenship _________________________________________________
Religion _________________________________________________
Height _________________________________________________
Weight _________________________________________________
Hair Color _________________________________________________
Eye Color _________________________________________________
17.Husband's Education:
High School College Other
Name/Address _________________________________________________
Dates Attended _________________________________________________
Major _________________________________________________
Degree _________________________________________________
Date of Graduation ______________________________________________
18.Wife's Education:
High School College Other
Name/Address _________________________________________________
Dates Attended _________________________________________________
Major _________________________________________________
Degree _________________________________________________
Date of Graduation ______________________________________________
19.Medical History: Husband
Diagnosis/Treatment ___________________________________________
Dates: ___________________________________________
20.Medical History: Wife
Diagnosis/Treatment ___________________________________________
Dates: ___________________________________________
21.Employment: Husband
Present Employer _____________________________________Date_______
Position ________________________________________________
Prior Employer _____________________________________Date_______
Position ________________________________________________
22.Employment: Wife
Present Employer _____________________________________Date_______
Position ________________________________________________
Prior Employer _____________________________________Date_______
Position ________________________________________________
23.Military Service
(Husband) ______________________________________________________
(Wife) ______________________________________________________
24.Arrests (Full Details Excluding Minor Traffic Violations)
Husband ______________________________________________________
______________________________________________________
Wife ______________________________________________________
______________________________________________________
25.Financial Statement:
Salary/Income _________________________________________________
Other Income State Source _______________________________________
Real Estate _________________________________________________
Savings _________________________________________________
Automobiles _________________________________________________
Stocks/Bonds _________________________________________________
Any Other Property ______________________________________________
Total Debts/Liabilities _________________________________________
Total Monthly Payments On Above Debts ___________________________
26.Insurance
Husband Wife
Accident ______________________________________________________
Health ______________________________________________________
Life ______________________________________________________
27.Personal References:
Name Address
1. ______________________________________________________________
2. ______________________________________________________________
3. ______________________________________________________________
28. Other Persons Residing in Your Home
Name Age Relationship
____________________________________________________________________
NOTE: IN ORDER TO PROCESS THIS APPLICATION, WE WOULD APPRECIATE ANSWERS TO THE
FOLLOWING PERSONAL QUESTIONS:
1. Have either of you ever been informed that you are infertile or do you
have
reason to believe that such might be the case?
2. Have you ever made an application to any other adoption agency or are you
now working through another such agency?
3. What were you told about the results of any previous adoption application?
4. What age and gender do you prefer in an adoptive child?
We have read and answered the foregoing questions to the best of our
knowledge.
Any additional details are listed below or on the reverse side of this page.
Signed __________________________________ Date _________________
Husband
Signed __________________________________ Date _________________
Wife
