Prelimary Information Statement

E-mail Address:
HUSBAND
Full Name:
Birth Date:
Birth Place:
Church Affiliation:
Occupation:
Place of Employment:
Education:

WIFE
Full Name:
Birth Date:
Birth Place:
Church Affiliation:
Occupation:
Place of Employment:
Education:

Address:
City, State, Zip Code:
Phone Number:
Date and Place of Marriage:
Dates of Previous Marriages:
Children's Names and Birth Dates:
Annual Combined Income and Source:
Do you have a criminal, domestic violence, or substance abuse history?
Do you have a serious physical or mental health disorder?
Have you ever applied with another agency?
How did you hear about our agency?
What has made you interested in adoption?

What kind of child would you like to consider? Include age, sex and racial background.