Untitled Document

My Selection Form

To help you with your selection, we will need the following information. Call, fax, or mail the form to our agency. We will send you a variety of selections to review.

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Today's Date		Date I need information

Send Information to me via		Mail		Fax
		I will review in your Office
		Date / Time

Name
Organization
Address
Box #
City / Zip

Telephone	Work		Ext		AM / PM
	Residence				AM / PM
Fax			Work / Home

I plan to adopt a total of

Families

Individuals

Seniors

Family with Children			Adult Individuals			Senior Citizens
Number of Children			Total?			Total?

Ages (e.g., 5-15 Yrs; Infant; Any)			Male	Female	Both	Male	Female	Both

With the following Parents			Ages
Mother	Father	Both Parents

Any other special kind of people you are looking for?

Created by Alpha Huskie. 1 August 2004.