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	Contact Information
	First Name: Last Name:    Spouse's Name:  if none, leave blank      Address:    City: State:   Select State Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick Newfoundland New Hampshire New Jersey New Mexico New York North Carolina North Dakota Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming None of These Zip:    Country:    Email Address:    Phone:      How do you prefer to be contacted?  Phone        Email        No Preference       I am interested in adopting from the following countries: Primary  Interest:  Select Country Cambodia China Guatemala Korea Taiwan Ukraine Vietnam Undecided Secondary  Interest:  Select Country Cambodia China Guatemala Korea Taiwan Ukraine Vietnam Undecided I am ready to begin the adoption process in:     0-3 months       4-6 months       7-12 months       1 - 2 years       Just gathering information     I first learned about FHSA from:  First Select  One of These:   Internet       Print       Radio       Personal Referral       Other      Second Select  One of These: Make Selection Here    Please tell us the details of the "other"  Additional Comments: