Adoption Application

Global Adoption, Counseling, Cultural Resources, Inc.

3620B, Creel Ct. Lexington KY 40517

Phone & Fax: (859) 971-2942, Executive Director: Lina Fong, PhD, LCSW, ACSW

ADOPTIVE APPLICATION

Adoptive Mother: ____________________________________ ___________________ ________________________

(Last) (First) (Middle) (Date of Birth) (Social Security No.)

Adoptive Father: ____________________________________ ___________________ _________________________

(Last) (First) (Middle) (Date of Birth) (Social Security No.)

Address: _________________________________________________________________________________________

(Street Address) (City) (State) (Country) (Zip Code)

How long have you lived at the above address _________________________________________________________

Previous Addresses last 5 years _____________________________________________________________________

Phone No:__________________________FaxNo:___________________Email:____________________________

Adoptive Mother Info: Work Phone ______________________E-mail ____________Cell_____________________

Occupation______________________Employer________________________________________________________

Length of Employment ________________Annual Income _______________Education (highest level reached, name of

institution)_____________________________________Race_____________Religion______________________

Adoptive Father Info: Work Phone ______________________E-mail ____________Cell_____________________

Occupation______________________Employer________________________________________________________

Length of Employment _________________Annual Income _______________Education(highest level reached,

name of institution)_____________________________________Race_____________

Religion______________________

Name/age/relationship of children and others living at home______________________________________________

_______________________________________________________________________________________________

Date of marriage ___________________Have you been previously married__________________________________

If so, list which spouse and separation/divorce/death date________________________________________________

List name and age of children from previous marriage(s) _________________________________________________

_______________________________________________________________________________________________

Have either of you been convicted of felony, violence, involved in a civil suit, paying judgment fine for charges.

Yes ____No___. If you answer is yes to any of the above, please describe and explain on the back of this application

How did you learn about us: Friend____ yellow page____ Internet ____Newspaper _______Other (specify) ________

The above information is true and complete to the best of my knowledge and belief. I (we) am (are) aware that falsification

of information or misrepresentation of facts will result in rejection of my (our) application.

_______________________________________________________________________________________________

Adoptive mother signed Date Adoptive father signed Date

The $50 application fee must accompany the completed application form

Date application received by agency __________________Application fee received___________________