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The SOURCE: Surrogacy
The Donor SOURCE
Initial Application
Please fill out the entire form below to be considered for our surrogacy program.
*Fields are required.

If you have any questions, please contact us at
Contact Information
Enter your full legal name:    
First Name:*
Last Name:*
If married, enter your spouse’s full legal name:    
First Name:
Last Name:
Home Phone:*
Daytime Phone:*
Mobile Phone:
What are the best times to reach you and at which number:*
Home Address:*  
Street 1:
Street 2:
State / Zip:
Mailing Address:* Same as Home Address
Street 1:
Street 2:
State / Zip:
Being a surrogate requires that you be able to attend many different doctors visits, many with a fertility specialist, who generally work in larger metropolitan areas. Which metropolitan area is closest to you?*
If you were referred to The Surrogacy SOURCE by a friend, clinic/doctor or an advertisement, please indicate below. Please provide as much information as possible. For example, If you found us through an advertisement indicate where, or if you were referred by a clinic/doctor provide their name.*
Additional Referral Details:

Personal Profile
Date of Birth:*
Height:* Ft.   In.
Weight:* lbs
Please check ALL that apply.
You may check more than one.
East Indian
Middle Eastern
Native American
(i.e. Chinese, Japanese)
(i.e. African-American, Caribbean)
(i.e. White, European)
(i.e. Asian Indian)
(i.e. Latino, South American, Puerto Rican)
(i.e. Arab, Moroccan)
(i.e. Alaskan Native, Cherokee)

General Questions
1. Please acknowledge that you understand that as a surrogate you must agree to maintain permanent residence in your current state until after delivery of the child/children.* Yes No
2. Do you receive any type of public assistance (welfare/food stamps /WIC/MediCal)?* Yes No
3. I have given birth to a child that I am currently raising in my own home. Please note that this is required in order to become a surrogate.* Yes No
4. Are you an experienced surrogate (have you been a surrogate before?)* Yes No
5. Are you currently nursing?* Yes No
6. Do you have a valid driver’s license, reliable car and car insurance?* Yes No
7. Do you and your partner understand that you must abstain from sexual intercourse during the IVF phase of the process (A period of 2-4 weeks)?*
Yes No
8. Have you been arrested over the age of 18?* Yes No
9. Has your partner been arrested over the age of 18?* Yes No
10. Do you currently smoke?* Yes No
11. Have you or your partner ever received treatment for depression?* Yes No
12. Have you ever had an eating disorder?* Yes No
13. Do you currently use recreational drugs (i.e. marijuana, cocaine, etc)?*
*Please note that you will be drug tested at your medical evaluation.
Yes No
14. Have you ever received treatment for drug/alcohol abuse?*
If Yes, describe below:
Yes No

I enter my full name and today’s date in the fields below as a verification of the information I have provided above. I certify that all information provided is honest and factual.*
Print Name:
Date (00/00/0000):