A Child Waits Foundation Application Date: _________________________

Male Applicant Female Applicant

Name: ________________________________	Name: ________________________________
Age: ______ Occupation: _______________	Age: _____ Occupation: _________________
Employer: ____________________________	Employer: _____________________________
Work Address: _________________________ ______________________________________	Work Address: _________________________ ______________________________________
Social Security #: _______________________	Social Security #: ________________________
Marital Status: Single _____ Married _____	Marital Status: Single ______ Married ______

Home Address: _________________________________________________________________

_______________________________________________________________________________

Phone #: __________________ Fax#: __________________ Email: ____________________

# of Children in Family: _______________ Ages of Children: __________________________

Adoption Agency Name and Address: ________________________________________________

_______________________________________________________________________________

Phone Number: __________________________ Contact Person: ________________________

Home Study Agency Name and Address: _____________________________________________

_______________________________________________________________________________

Phone Number: __________________________ Contact Person: ________________________

INS 1600A Filed: Yes _____ No _____ If yes, anticipated completion date: _____________

Is there a child(ren) assigned to you? Yes ____ No ____ # of Children/ages: _____________

Country of Adoptive Child(ren): _______________ Expected Date Of Travel: ______________

How did you hear about A Child Waits Foundation? ____________________________________