ACKNOWLEDGEMENT and REQUEST

for an

"APPLICATION FOR THE PLACEMENT OF A CHILD FOR ADOPTION"

We have read and understand the INFORMATION FOR POTENTIAL ADOPTIVE APPLICANTS and agree to abide by these policies and procedures. We understand that fees will be reviewed annually and may be increased.

We wish to proceed by requesting an "Application for the Placement of a Child for Adoption". Enclosed with this signed acknowledgement is our application fee of $150.00.

 

 

Signature

 

Date

 

 

Signature

 

Date

Please print name, address, phone number and email address:

NAME: 

ADDRESS: 

CITY: 

PROV: 

POSTAL CODE: 

PHONE: 

EMAIL: 

 

RETURN TO:

JEWELS FOR JESUS ADOPTION AGENCY INC.
6655 KITIMAT ROAD, UNIT 5
MISSISSAUGA, ON  L5N 6J4