The search engine you used to find us:

Identifying Information:

Single:
Sex:     Male   Female     Date of Birth:    Soc. Sec.#:
Place of Birth:    Education:

Employment:
Occupation/Title:   Employer:
Length employed:   Salary/Wages:

Husband:
Date of Birth:    Soc. Sec.#:
Place of Birth:    Education:

Employment:
Occupation/Title:   Employer:
Length employed:   Salary/Wages:

Wife:
Date of Birth:    Soc. Sec.#:
Place of Birth:    Education:

Employment:
Occupation/Title:   Employer:
Length employed:   Salary/Wages:

Why are you considering adoption from China?

Province or city you prefer to adopt from (if any):

Child Desired: male female either Preferred age range:

Please list conditions you're willing to consider even if they may appear to be minor:

* Is your home study agency licensed in your state? Yes No

* Homestudy status: Not started In process Completed date:

* I-600A (INS) application: Not filed Pending  Approved date:

* Passport status:
Single:      not applied for applied valid expires:
Husband: not applied for applied valid expires:
Wife:         not applied for applied valid expires:

* Are you willing to accept Post-Placement Survey and any additional reporting requirements in the event a child is placed with you?
Yes No

Emergency Contacts:
Please list two people you are in close contact with whom we may contact if we need to reach you but are unable to locate you:
Name:Phone #:
Name:Phone #:

Health:
Do you have any medical conditions? Yes No
If "Yes", please describe:
When does your health insurance cover an adoptive child?
Does it cover pre-existing conditions? Yes No

Your Name:       
E-mail Address:
Date:                    

If you experience problems with this form, please try another application form. Thank you!

If you choose to pay the application fee of $100 by check or money order, please make it payable to "Sino-America Bridges", send to:

Sino-America Bridges
5250 N. Sheridan Rd., #306
Chicago, IL60640

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