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2000 S. Dixie Highway, Suite 104, Coconut Grove, Florida 33133
Telephone: 305 358 2442/2445   •  Facsimile: 305 433 7817
web: www.adoptintl.com   •  email: info@adoptintl.com
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Application For Adoption

Please complete the following information as completely and accurately as possible so that we can properly advise you as to which program(s) is best suited for you. If you need assistance, please call (305) 358-2442.  All information that you disclose in this application is strictly confidential. If mailing it, please print clearly. Our application fee is $200.
 
  SECTION I:  APPLICANT(S) INFORMATION

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

      
Petitioner Passport Number
 Place of Issuance
 Date of Expiration
      
Spouse Passport Number
 Place of Issuance
 Date of Expiration
      
 
  SECTION II:  PETITIONER 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
 ,

Please indicate any health problems in the designated boxes below:
Petitioner Past health Problems
 Petitioner Present Health Problems
Spouse Past health Problems
 Spouse Present Health Problems
Child 1 Past health Problems
 Child 1 Present Health Problems
Child 2 Past health Problems
 Child 2 Present Health Problems
Child 3 Past health Problems
 Child 3 Present Health Problems
 
 
  SECTION V:  PROGRAM PREFERENCES
countries

Which country program are you interested in?  
Desired age of child: Desired sex of child:
Will you accept siblings Will you accept a child with medical conditions?
Comments:
 
  SECTION VI:  PROCESS INFORMATION
« Learn more about the application steps

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
 ,

Have you applied to the US Immigration and Naturalization Service (form I-600a)?  No Yes
Date of Application
 ,   		Date Fingerprinted:
 ,   		   

Have you received your I-171h, Notification of Favorable Determination Concerning Application for Advance Processing of Orphan Petition? No Yes
Date Received
 ,
     

What are your reasons for choosing international 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 international adoption program.
Petitioner'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 $200 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) 358-2442.

Submit by mail: Submit By Fax: Submit Online:

AdoptInternational, Inc.
1040 Biscayne Blvd., Suite 3306
Miami, FL 33132

(305) 433-7817
 
 

 

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