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預收養父母基本情況表       

INFORMATION ABOUT PROSPECTIVE ADOPTIVE PARENTS              

                                                                  DATA：

 

項 目 Item	收 養 父 親 Adoptive Father	收 養 母 親 Adoptive Mother
姓 名 Name
出生日期 D.O.B
國 籍 Citizenship
受教育狀況 Education
身體狀況 Health Status
婚姻狀況 Marital Status
職 業 Occupation
年收入 Annual Incomes
是否受過刑事處罰 If there is any criminal record	是/否	是/否
凈資產 Net Worth
子女情況 Children at Home
撫育特需兒童的有利條件 Advantages of Nurturing
收養愿望 Adoptive Expectation
遞交文件時間 Submission Date of Application

 

*填表須知見背面

 

(The reverse side)

 

Points for Attention

 

1. This form should be filled in truthfully by the authorized adoption organization according to the actual situation of the family;

 

2. In the Health Status column, it should be truthfully stated whether the person has ever suffered any serious disease/contagious disease, major operation, and ever had history of alcoholism/drug abuse; if there is any such incidents mentioned above, please state in detail;

 

3. In the Marital Status column, please state accurately the date of present marriage, whether any previous marriages, the number of previous marriages, the cause of ending each previous marriage, the dates of beginning and ending of each of them etc.

 

4. In the Children at Home column, children include children born out of the present marriage and previous marriages, children born out of wedlock, and adopted children; if there is any, please state their age, health status; the over-ten-year old children's attitude toward their parents' application of adoption; the grown-up children may not be included.

 

5. In the Criminal Punishment column, if there is any criminal punishment, please put down in detail the incident, date and punishment.

 

6. This form is merely used by the China Center of Adoption Affairs for preliminary verification; should there be any big discrepancy between the contents of the family's actual situation and the contents in this form, the former shall prevail.

 

(China-ccaa.org October 16, 2006)