PRE-QUALIFYING QUESTIONNAIRE

Thank you for your interest in becoming a surrogate. Please accurately complete and submit the form below. If you qualify, we will be in touch with you soon.

                

                        
Your Name:*

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Phone number:*
Email:*

                            
                        
Your Home Address:*    
                    

                         
                                        Street Address
                                        
                                   
                                    City
                                    
                                 
                                        State
                                        AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
                                      
                                    ZIP Code
                                    
                                
                    

                
Are you a legal US citizen?*

			

				
				YES
			
			

				
				NO
			
Your Age:*
 
Your Height: (ex: 5'6")*
 
Your Weight:*
 
Are you a smoker?*

			

				
				YES
			
			

				
				NO
			
Do you have YOUR OWN reliable transportation?*

			

				
				YES - including car insurance
			
			

				
				YES - but without car insurance
			
			

				
				NO
			
			

				
				I have a reliable source but it is not my own.
			
What is your current PRIMARY source of income?*
 
_______________________________
Have you delivered at least one child?

			

				
				YES - full-term
			
			

				
				NO - was not full-term
			
			

				
				NO - I have never been pregnant
			
IF YES to the question above, do you have custody of your children?

			

				
				YES
			
			

				
				NO
			
			

				
				NO - I was serving as a surrogate
			
_______________________________
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