International Adoption Net
2305 E. Arapahoe Rd., #248
Centennial, CO 80122
Phone: 303-691-0808
FOR AGENCY USE ONLY
Application Received Date: _________ Check Enclosed:
Yes / No
Approved for formal app: Yes ____No ___ File number: _____________ Social Worker assigned to case:_________________
Rev 12/04
The information submitted in this application will be held strictly
confidential within the limits of state law.
IAN Preliminary Application Form
Applicant:
Work phone:
Age:
Spouse:
Work phone:
Age:
Address:
Street:
City:
State:
Zip:
Home Phone:
FAX:
Home Email:
Applicant Work Email:
Spouse Work Email:
Date&place of marriage:
Date of application:
Please give year of previous marriages and divorces,
if any:
Applicant:
Spouse:
Children:
Age of birth children
Age of adopted children:
Citizenship:
Applicant:
Spouse:
Why do you wish to adopt?
I am/we are interested in adopting the following child(ren):
Siblings?
Male Female Either
Age range
How many siblings?
Yes No
I am/we are interested in adopting a child from:
United States
Other country
I/we are using an out of state placement agency, (name
and phone)
Are you willing to adopt a child who has an incomplete
social or medical history?
Yes No
Are you willing to adopt a child you have never met,
or have only met briefly?
Yes No
Will both parents be able to travel to another country
to complete the adoption?
Yes No
Are you willing to attend training and support group
meetings before and after placement?
Yes No
Are you strongly motivated and willing to work hard
toward completing an adoption?
Yes No
Are you willing to adopt a child that is not a newborn
baby?
Yes No
Are you willing to accept a child with medical conditions
that can be cured?
Yes No
Are you willing to accept a child who has temporary
physical and developmental delays?
Yes No
Have you carefully considered your financial
resources and planned for adoption expenses?
Yes No
Have you carefully considered your ability to give time
and emotional energy to adoption?
Yes No
Are you particularly eager to parent a child with a
specific problem, condition or situation?
Yes No
If yes, please explain:
How did you learn about International Adoption Net?
Friend or Referral Internet Yellow Pages
Other:
It is imperative that you disclose all requested
information in an accurate manner, as the FBI fingerprint and
criminal clearance process required by law will disclose all
police charges and convictions. Charges or convictions do not
necessarily preclude you from an approved homestudy. All cases
are reviewed on a case-by-case basis. All information contained
in this application will be held strictly confidential within
the limits of state law.
Have either of you been charged with, or convicted of
a crime?
Yes No
If yes, charge and date:
Have either of you had problems with substance abuse,
i.e., alcohol, prescription drugs or other?
Yes No
Do either of you have medical conditions that may effect
your ability to parent a child?
Yes No
Have either of you ever been involved in, accused of,
or convicted of child abuse or neglect?
Yes No
Have either of you ever been involved in, accused of,
or convicted of domestic violence?
Yes No
Have you ever had a homestudy completed by another agency
or social worker?
Yes No
If yes, please list whether you were approved or not,
and the agency name and phone number:
For any of the above that you answered as "yes", please
attach a letter of explanation with the signature of both the applicant
and the spouse.
Applicant's Employer
Job title
Annual Salary
Spouse's Employer
Job title
Annual Salary
References: Please list 3 references not related to
you (their name, address and phone number and, if available, their
email).
1.
2.
3.
STATEMENT OF UNDERSTANDING
I/We understand that we are submitting this Preliminary Application
for the agency to assess whether International Adoption Net can
offer us adoptive services. I/we state that the information we have
given is true and complete. I/we understand the Preliminary Application
fee is non-refundable, and does not guarantee an offer of adoption
services through International Adoption Net nor does it guarantee
the placement of a child.
I/We have thoroughly read and understand the information regarding
the adoption services provided by International Adoption Net and
wish to obtain a formal application with the intent of applying
for adoption services if this Preliminary Application is approved.
I/We hereby give our permission for International Adoption Net
and our previous and/or current adoption agency(s) to share information
about us concerning our application(s) and assessments as adoptive
parents.
Applicant's Signature
Date
Applicant's Signature
Date
Please return this application form to:
International Adoption Net,
2305 E. Arapahoe Road, Suite #248
Centennial, CO 80122 Or contact our office over the phone at 303-691-0808 for credit card payment