Joint Application
A $75.00 application fee is required alongside the completed application form. Upon form submission, you will be directed to the payment page for processing.
Applicant #1
*
First Name
Middle Name
Last Name
Applicant #1 - SSN#
*
Applicant #2
*
First Name
Middle Name
Last Name
Applicant #2 - SSN#
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long at above address?
*
Applicant #1 - Cell
*
Please enter a valid phone number.
Applicant #2 - Cell
*
Please enter a valid phone number.
Applicant #1 - Email
*
example@example.com
Applicant #2 - Email
*
example@example.com
Applicant #1 Information
Date of Birth
*
-
Month
-
Day
Year
Date
Place of Birth
*
Are you a U.S. citizen?
*
Yes
No
Race
*
Religion
*
Highest Educational Degree Obtained?
*
Highest Educational Degree Obtained?
*
Occupation
*
Employer
*
Work Phone
*
Length of Employment
*
Annual Income
*
Applicant #2 Information
Date of Birth
*
-
Month
-
Day
Year
Date
Place of Birth
*
Are you a U.S. citizen?
*
Yes
No
Race
*
Religion
*
Highest Educational Degree Obtained?
*
College & Degree Area
*
Occupation
*
Employer
*
Work Phone
*
Length of Employment
*
Annual Income
*
Background Details
Date of Marriage
*
-
Month
-
Day
Year
Date
Place of Marriage
*
Have either of you been previously married?
*
Yes
No
Date of divorce
*
-
Month
-
Day
Year
Date
Full Name/Date of birth/ages of children living in home
*
Full Name/Date of birth/Relation of others living in the home
*
Any State, other than current state of residence, that an adoptive parent has resided in the last 10 years
*
Have you previously adopted a child?
*
Yes
No
Agency used
*
Have either of you ever been convicted for violation of any law (including expungements) or are you currently under charges for any violation?
*
Yes
No
Please explain:
*
Have either of you ever been diagnosed with a mental illness or addiction?
*
Yes
No
Please give diagnosis:
*
Have either of you received counseling?
*
Yes
No
Please give the reason:
*
Adoption Details
Type of adoption you wish to pursue
*
Domestic
International
Independent
Embryo
International: Which country?
*
Independent: Attorney's name
*
Independent: Attorney's Phone Number
*
Please enter a valid phone number.
Closing Questions & Declarations
How did you learn about Adoption Assistance?
*
The above data is true and complete to the best of my/our knowledge. We are aware that falsification or information and/or misrepresentation of facts will result in rejection of our application.
*
I agree
Applicant #1 Name (acts as your signature)
*
Date
*
-
Month
-
Day
Year
Date
Applicant #2 Name (acts as your signature)
*
Date
*
-
Month
-
Day
Year
Date
By entering your names above you are signing this application
A $75.00 application fee is required alongside the completed application form. Upon form submission, you will be directed to the payment page for processing.
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