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First Name:
Last Name:
Age:
Marital Status:
Spouse's Name (if applicable):
City:
State:
ZIP:
Email:
Best Number To Reach You:
Number of Children You're Interested in Adopting:
Age Preference:
Gender Preference: Boy Girl No Preference What countries interest you? (click all that apply)

Russia
Ukraine
Georgia
Armenia
Kazakhstan
United States
India
Mexico
Philippines
Ethiopia
Other Africa
Guatemala
Other South America
Haiti
Korea
China
Vietnam
Thailand
Other
Undecided

Comments:
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