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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: Is there anything else you'd like to share with us?
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