Bundles Of Joy LLC

SURROGATES PRELIMINARY APPLICATION

Please make sure you have read completely and thoroughly understand the Surrogate Information. Please email us at info@bundlesofjoyllc.com with questions. If you are interested in becoming a surrogate and would like to see if you are eligible for the Bundles of Joy surrogate program, please fully complete the questionnaire below. Incomplete questionnaires will be rejected. Note that this is only a preliminary application, but all information provided is be held in strictest confidence. Once submitted through our secure system, you will be contacted within fifteen (15) days and advised whether or not you qualify to proceed with the program.

Create A Username:	(no spaces or unique characters "Ex: $,!,.") Please do not include your name or email address in this field.
First Name:
Last Name:
Address:
Suite/ Apt:
City / State / Zip Code:
State:
Zip Code:
Country:
Phone Home:
Phone Cell:
E-mail Address:

Best time to contact:
Where can we leave a private phone message?:

Date of Birth:
Primary Race:
Secondary Race:
Marital Status:
Number of years (only if married):	(years)
Height:
Weight:	(pounds)
Blood Type:
Prior Surrogacy:

Occupation :
Major:
What is your HIGHEST level of Education?:
Do you or anyone in your household smoke?:
Do you drink?:
How often?:

Have you or your spouse ever been convicted of a felony?:
Are you currently taking any medication?:
If so, What medications do you take?:
Have you or your spouse/partner sought counseling in the past for emotional problems?:
If yes, please describe the reason:	You: - Spouse/partner:
Have you or your spouse/partner been in rehab for substance abuse?:
Do you or your spouse have any sexually transmitted disease?:
Have you or anyone in your family been diagnosed currently or in the past with one of the following:
-Depression?:
-Schizophrenia?:
-Mania?:
-Obsessive-compulsive disorder?:
-Bipolar?:
-Do you have any genetic diseases or illnesses that run in your family?:	If yes, please describe below:
Have you or your spouse/partner ever used any of the following recreational drugs, currently or in the past:
-Marijuana / Heroin / Cocaine / Barbiturates / Amphetamines / LSD?:
Do you or anyone in your family have any illnesses?:
If yes, please describe:

How many times have you been pregnant?:
Were all your children born healthy?:
Did any of your pregnancies take longer than 6 months to conceive?:
Describe any reproductive illnesses you have experienced (miscarriages, abortions, premature delivery or still births) include outcome, date, circumstances, etc.):
Comments:
	SUBMIT GESTATIONAL SURROGATE APPLICATION