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Surrogate Application

What is in a surrogate application? Important surrogate application information and sample surrogate application for you.

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Surrogate Application

SURROGATE APPLICATION

Surrogate Application and Information

Please fill out this surrogate application as completely as possible. If you do not want to put in you work phone number you do not have to. This surrogate application has to have something in every block with * or it will not allow you to submit.

We need as much information as possible to help match you with the right intended parents.

Of course it does not obligate you to anything nor does it guarantee we will be able to find an intended parent match. You have full choice here. Surrogacy is getting more acceptance all the time. The American Fertility Association just reported that the traffic to their site doubled last year. Also, there will be a formal contract prepared by an attorney with experience in surrogacy for everyone's protection.

In these bad economic times this seems like a great way to earn some extra money for your family.

Do you want to buy something that you have been putting off?

Do you need a new car?

Do you want to start a business?

Don't wait. Fill out application below now.

Thank you,

Delwyn Lounsbury

You can reach the Home Page at link below the surrogate application.

Surrogate Application

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Country*
Country*

Home Phone*
Home Phone*

Business Phone

Date of Birth*
Date of Birth*

Height*
Height*

Weight*
Weight*

Do you receive aid/welfare?*
Do you receive aid/welfare?*

	A Welfare
	B Food Stamps
	C Other

If other - What type?*
If other - What type?*

Do You Smoke?*
Do You Smoke?*

	A Yes
	B No
	C Other

Have You Given Birth Before?*
Have You Given Birth Before?*

	A One child
	B Two
	C Three +

Gastric Bypass Surgery?*
Gastric Bypass Surgery?*

	A Yes
	B No
	C

Do You Take Any Medications -What?*
Do You Take Any Medications -What?*

Do You Have Car?*
Do You Have Car?*

	A No
	B Yes
	C

Past Medical Problems?*
Past Medical Problems?*

How Many Sexual Partners - 1 year*
How Many Sexual Partners - 1 year*

	A One
	B Two
	C Three +

How Many C Sections?*
How Many C Sections?*

	A None
	B One
	C Two

What Is Your Motivation & How High?*
What Is Your Motivation & How High?*

Education?*
Education?*

	A High School/ GED
	B Some College
	C College Degree

You or Partner Convicted of Felony?*
You or Partner Convicted of Felony?*

	A No
	B Yes
	C

Ever Attempted Suicide?*
Ever Attempted Suicide?*

	A No
	B Yes
	C

High Blood Pressure?*
High Blood Pressure?*

	A No
	B Yes
	C

Diagnosed - Diabetes?*
Diagnosed - Diabetes?*

	A No
	B Yes
	C

Incompetent Cervix?*
Incompetent Cervix?*

	A No
	B Yes
	C

Diagnosed with Syphillis?*
Diagnosed with Syphillis?*

	A No
	B Yes
	C

Medical Insurance? What Company?*
Medical Insurance? What Company?*

Any Placenta Previa?*
Any Placenta Previa?*

	A No
	B Yes
	C

Any Toxemia?*
Any Toxemia?*

	A No
	B Tes
	C

Any Pre-Eclampsia?*
Any Pre-Eclampsia?*

	A No
	B Yes
	C

Any Pregnancy-induced Hypertension?*
Any Pregnancy-induced Hypertension?*

	A No
	B Yes
	C

How Did You Hear About US?*
How Did You Hear About US?*

Surrogate Application
Home Page

Contact Us Re: Surrogacy & Egg Donation
Please note that all fields followed by an asterisk must be filled in.
SURROGATE MOTHER - PUT x HERE WRITE NOTE OR ASK A QUESTION
INTENDED PARENT - PUT x HERE WRITE NOTE ASK A QUESTION
EGG DONOR - PUT x HERE WRITE NOTE ASK A QUESTION
First Name* First Name*
Last Name* Last Name*
E-mail Address* E-mail Address*
Street Address
City* City*
State/Prov* State/Prov*
Zip/Postal Code
Country* Country*
Home Phone* Home Phone*
Please enter the word that you see below.

Have A Great Comment About This Topic?

Do you have a great story or comment? Would you be offended if I asked you to share it?
No. Great! Let's not just sit on our hands and let life go by without living it to the fullest. Tell others to come also to this forum! The more the merrier. Let's at least talk about it here. Thank you in advance for the help in getting this forum going. Up load some pictures please.
Delwyn (Dell) Lounsbury

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