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ONLINE APPLICATION FORM

Apply here or Click here for answers to your questions, feel free to email us or call us at 305-358-2445 for more information!
 
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1040 Biscayne Boulevard, Suite 3306 • Miami Florida 33132
Telephone: 305-358-2445 • Facsimile: (305) 433-7817
web: www.adoptamerica411.com • email: info@adoptamerica411.com
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Application For Adoption

Please complete the following information as completely and accurately as possible. If you need assistance, please call 305-358-2445 All information that you disclose in this application is strictly confidential. If mailing it, please print clearly. Our application fee is $250. You can download, print and fax this application to 305.433.7817.
 
  SECTION I:  APPLICANT(S) INFORMATION

Applicant Last Name First Name
MI
      
Spouse Last Name
 Spouse First Name
MI
      
Street Address
 City
 State
 		Zip
    
Home Phone
 Applicant Work Phone
 Applicant Alternate Phone
 Applicant Fax
  Spouse Work Phone
 Spouse Alternate Phone
      
Applicant Email
 Spouse Email
        
Emergency Contact Name
 Emergency Contact Phone

      
 
  SECTION II:  Applicant BACKGROUND INFORMATION

Date of Birth
 ,
Social Security No. Citizenship
      
Place of Birth
 Race
      
Employer Name
 Employer Address
 Annual Salary

   
Length of Employment
 Health Coverage
      

Years Married:      Prior Marriage?      Number of Previous Marriages:
Have you ever been convicted of a crime (misdemeanor or felony)? :

     
Are there any past incidents of your being reported for physical abuse? 

If so, please explain below:

      
Are there any past incidents of drug or alcohol abuse?

If so, please explain below: 
     
 
 
  SECTION III:  SPOUSE BACKGROUND INFORMATION [IF APPLICABLE]

Dateof Birth
 ,
Social Security No
 Citizenship
      
Place of Birth
 Race
      
Employer Name
 Employer Address
 Annual Salary

   
Length of Employment
 Health Coverage
      

Years Married:      Prior Marriage?      Number of Previous Marriages:


Have you ever been convicted of a crime (misdemeanor or felony)? :


     

Are there any past incidents of your being reported for physical abuse? 
If so, please explain below:


      

Are there any past incidents of drug or alcohol abuse?
If so, please explain below: 

     
 
 
  SECTION IV:  OTHER CHILDREN LIVING IN YOUR HOME (IF APPLICABLE)

Child 1 Name
 Relationship
 		Date of Birth
 ,
Child 2 Name
 Relationship
 		Date of Birth
 ,
Child 3 Name
 Relationship
 		Date of Birth
 ,
Child 4 Name
 Relationship
 		Dateof Birth
 ,
Child 5 Name
 Relationship
 		Date of Birth
 ,
Child 6 Name
 Relationship
 		Date of Birth
 ,

  SECTION V:  PREFERENCES

Race of Child:
Special needs:
Additional comments:
 
  SECTION VI:  PROCESS INFORMATION

Agency Name
 Street Address
   
City
 State
   		Zip

Have you begun your home study? No Yes (please specify below)
Agency Name
 Social Worker
Street Address
  
City
 State
   		Zip
 Completion Date
 ,

What are your reasons for choosing adoption?

If you are mailing or faxing this form, please certify by completing the entries below. If you are submitting this form online, please enter name(s) in the "Printed Name"sections only
I/We represent that all information in this application is true, accurate, and complete, and is given to AdoptInternational for entry to its adoption program.
Applicant's Signature
Printed Name
 Date
Spouse's Signature
Spouse's Printed Name
 Date


Please submit your signed and completed application along with our application fee of $250 by selecting an option below.  (Online and faxed submissions must be followed with our application fee mailed separately.) If you need assistance, please call us at 305-358-2445.

Submit by mail: Submit By Fax: Submit Online:
Adopt America
1040 Biscayne Blvd. , Suite 3306
Miami Florida 33132		 (305) 433-7817
Copyright © 2008 Adopt America • All rights reserved.