Surrogate Application Before ProceedingPlease review the Surrogate Qualifications on our Gestational Carrier page before starting your application.Name* First Middle Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Can we leave a message at the above number?*YesNoEmail* Enter Email Confirm Email You will receive a confirmation email. Please check your inbox often. Preferred Method of Contact*PhoneEmailAge* You must be between 21 and 40 to apply. Height* Weight* Marital Status*SingleMarriedSeparatedDivorcedAre you a US citizen or permanent resident of the US?* US Citizen Permanent Resident Neither Are you currently employed?* Yes No Please list occupation:* Number of Children* You must have given birth to and parented at least one child in order to apply.Have you been a surrogate before?* First-time surrogate Experienced surrogate Number of surrogate deliveries:*Total number of C-Sections:*Have you had any complications with pregnancy or delivery? (Check all that apply)* Premature Birth Still Birth Miscarriage Physician Ordered Rest Gestational Diabetes Toxemia/Preeclampsia Ectopic pregnancy Placenta Previa Other None Please list complication(s)* Have you ever had an abnormal Pap smear?* Yes No If yes, please explain:* Do you have any existing medical conditions?* Yes No If yes, please explain:* Are all of your immunizations up to date (measles, mumps and rubella (MMR); chicken pox; and hepatitis B)?*YesNoWhat are you missing?* Do you have a history of mental illness?* Yes No Do you smoke or vape any substance?* Yes No Does anyone in your household smoke or vape any substance?* Yes No If yes, please explain:*Do you drink alcohol?* Yes No Occasionally Do you or your spouse/partner have a history of substance abuse?* Yes No If yes, please explain:*Do you or your spouse/partner have a criminal history?* Yes No Who is your current health insurance provider?* Do you currently receive any financial support from the government that is not related to military benefits? (i.e. housing or food assistance, Medicaid, etc.)* Yes No If yes, please explain:* Do you have a driver's license?* Yes No Do you have your own car?* Yes No Why are you interested in becoming a surrogate?*How did you hear about Western Surrogacy?*InstagramFacebookGoogle/Search EngineReferred by SomeoneOtherWho referred you?* By checking this box, I give my express written consent for Western Surrogacy to call, text, or email me with marketing offers or other messages regarding services about which I have inquired at the phone number I have provided. I agree to the Privacy Policy. I agree to receive other communications from Western Surrogacy. I agree to the receive other communications by Western Surrogacy.
