12.07.2015 Views

2049 Ridge A en e E anston Illinois 847 475 5800 FAX ... - The Cradle

2049 Ridge A en e E anston Illinois 847 475 5800 FAX ... - The Cradle

2049 Ridge A en e E anston Illinois 847 475 5800 FAX ... - The Cradle

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INTERAGENCY CLIENT APPLICATION FORMHusband or Single/Primary Applicant Wife_____________________________________________ ______________________________________________Name: First Middle Last Name: First Middle LastUse names as they appear in passports______________________________________________________________________________________________Address: Street______________________________________________________________________________________________Town/City State ZIPContact Information:Home Phone: _________________________________Cell Phone: ___________________________________Work Phone: __________________________________Email (most frequ<strong>en</strong>tly used): __________________________________________________________________Fax (most frequ<strong>en</strong>tly used): ______________________Cell Phone: ___________________________________Work Phone: __________________________________Email (most frequ<strong>en</strong>tly used): __________________________________________________________________Personal Information:Date of Birth _________________________________Place of Birth _________________________________Citiz<strong>en</strong>ship ___________________________________Social Security # _______________________________Occupation ___________________________________Income ______________________________________Employer ____________________________________Passport nr. __________________________________Date of Birth _________________________________Place of Birth _________________________________Citiz<strong>en</strong>ship ___________________________________Social Security # _______________________________Occupation ___________________________________Income ______________________________________Employer ____________________________________Passport nr. __________________________________Issue date: ___________________________________Issued by: ___________________________________Issue date: ___________________________________Issued by: ________________________________________________________________________________________________________________________________Date of Marriage Place of Marriage Previous Marriage(s) – if applicableList date(s) of marriage/divorceNames of Childr<strong>en</strong> from allMarriages/Relationships(indicate if not living with you)AgeDate of BirthDate of Arrival(if adopted)Country of Birth(if adopted)Name, relationship, and age of any/all other persons living in your home:________________________________________________________________________________________<strong>2049</strong> <strong>Ridge</strong> A <strong>en</strong> e E <strong>anston</strong> <strong>Illinois</strong> <strong>847</strong> <strong>475</strong> <strong>5800</strong> <strong>FAX</strong> <strong>847</strong> <strong>475</strong> 5871


HOMESTUDY AGENCY INFORMATIONName and address of your Home Study ag<strong>en</strong>cy:____________________________________________________________________________________________________________________________________________________________________________________________Adoption Counselor’s Name: ______________________________________ Phone Number: __________________Counselor’s E-mail: _____________________________________________________________________________Adoption Supervisor’s Name: ______________________________________ Phone Number: __________________Status of CIS Filing: ____________________________________________________________________________CHILD PREFERENCE:Please indicate preferred age range of child ___________________________________________________________G<strong>en</strong>der prefer<strong>en</strong>ce? [ ] No [ ] Yes If yes, which one? ___________________________________Are you op<strong>en</strong> to considering a child with medical problems that may require long term care and/or surgical interv<strong>en</strong>tion?[ ] Yes [ ] NoAre you requesting siblings?[ ] No [ ] YesPlease sign and date this docum<strong>en</strong>t. Thank you!I/We agree that the information provided above is true and accurate to the best of our knowledge. By signing thisapplication, I/we understand I/we are giving cons<strong>en</strong>t for <strong>The</strong> <strong>Cradle</strong> to communicate with our home study ag<strong>en</strong>cy namedabove. I/We hereby acknowledge that I/we have read and fully understand the policies, procedures, and requirem<strong>en</strong>ts of<strong>The</strong> <strong>Cradle</strong> as stated in the International Adoption Services Agreem<strong>en</strong>t and Program Description.Husband or Single Applicant_______________________________________SignatureDate: __________________________________Wife_____________________________________SignatureDate: ________________________________Please s<strong>en</strong>d this completed application and $250 application fee payable to:<strong>The</strong> <strong>Cradle</strong>, <strong>2049</strong> <strong>Ridge</strong> Av<strong>en</strong>ue, Ev<strong>anston</strong>, IL 60201. Attn: Russia ProgramPlease include a photocopy of the information page of your passports along with any name-change pages, if applicable.It is necessary for you to set up your own FedEx account at this pointto facilitate the shipping of visas and docum<strong>en</strong>ts in a timely manner.FedEx Account: #____________________If you have questions, please contact us at (<strong>847</strong>) 239-3956, or s<strong>en</strong>d e-mail to JStigger@cradle.orgThank you!<strong>2049</strong> <strong>Ridge</strong> Av<strong>en</strong>ue Ev<strong>anston</strong>, <strong>Illinois</strong> <strong>847</strong>-<strong>475</strong>-<strong>5800</strong> <strong>FAX</strong> <strong>847</strong>-<strong>475</strong>-5871www cradle org

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