Surrogate application form. Date of Application _________ Married _________ Single _________ Widowed _________ Separated _________ Divorced _________ Name _________ Address _________ Home Phone No. ( ) Age _________ Date of Birth _________ Social Security No. _________ Drivers License No. _________ Occupation _________ Business Phone No. ( ) Employer _________ Employer's Phone No. ( ) Employer's Address _________ Husband's Name (if applicable) _________ Husband's Occupation _________ Business Phone No. ( ) Husband's Employer _________ Employer's Address _________ Dates of all marriages _________ Dates of divorces _________ Other _________ City, County & State of all marriages _________ Number of Pregnancies _________ Date of each pregnancy _________ Number of Miscarriages _________ Date of each miscarriage _________ Number of Abortions _________ Date of each abortion _________ Number of Stillbirths _________ Date of each stillbirth _________ Present Obstetrician/Gynecologist _________ Phone ( ) Address _________ Number of children at home _________ List names, ages, birthdates & addresses of all children: _________ Present Pediatrician _________ Phone No. ( ) Address _________ Address _________ Race _________ Blood Type _________ Allergies _________ Height _________ Weight _________ Hobbies _________ Ethnic _________ Education _________ Hair color _________ Eye color _________ Complexion _________ Religion _________ Do you smoke cigarettes? _________ How often? _________ Do you drink alcohol? _________ How often? _________ Are you presently using marijuana? _________ How often? _________ Have you ever used marijuana? _________ How often? _________ Have you ever used illegal or unprescribed drugs? _________ What drugs and how often? _________ Are you presently using illegal or unprescribed drugs? _________ If so, what drugs and how often? _________ Please list all medications you are presently taking and the reason(s) for each: _________ What birth control method do you use? _________ Do you have any congenital diseases in your family? _________ Medical Insurance: Yes _________ No _________ Maternity Benefit Coverage _________ Life Insurance: Yes _________ No _________ Amount Payable _________ Beneficiary _________ Surgery: Yes _________ No _________ Reasons and results of surgeries _________ Annual Income (Include husband's if applicable) _________ Reasons for applying for surrogate procedure _________ Please attach recent photograph of applicant and all children. These photographs cannot be returned. Please include a family medical and genetic history tracing back as far as possible. I, the undersigned, swear and affirm that the above statements are true and correct to the best of my knowledge. Signature _________ Date _________ Please state expected pregnancy & confinement fee: $_____