| Name of prospective adoptive mother * |
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| Name of prospective adoptive father (if applicable) |
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| Address * |
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| Email * |
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| Telephone * |
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| Marital status * |
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| Date of birth Prospective adoptive mother * |
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| Date of birth Prospective adoptive father (if applicable) |
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| Does either parent have a medical condition? * |
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| Do you already have children? * |
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| If you have children, what are their ages? |
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| Country of choice * |
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| If you are applying to adopt in India, will you apply as - |
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| How many children do you wish to adopt at this time? * |
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| What ages of child might you apply to adopt? * |
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| Would you consider accepting a child with some medical needs? * |
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| Which Home Study Agency do you intend to use? * |
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| Where are you up to in the process? * |
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| Payment method for $230 fee * |
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| Payment date * |
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| Comments |
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