Appendix 4--Information About the Prospective Adoptive Parents
GOV.cn Wednesday, August 31, 2005

预收养父母基本情况表        
INFORMATION ABOUT PROSPECTIVE ADOPTIVE PARENTS               

                     DATA

项 目
Item

收 养 父 亲
Adoptive Father

收 养 母 亲
Adoptive Mother

姓 名
Name

   

出生日期
D.O.B

   

国 籍
Citizenship

   

受教育状况
Education

   

身体状况
Health Status

   

婚姻状况
Marital Status

 

职 业
Occupation

   

年收入
Annual Incomes

   

是否受过刑事处罚
If there is any criminal record

是/否

是/否

净资产
Net Worth

 

子女情况
Children at Home

 

抚育特需儿童的有利条件
Advantages of Nurturing

 

收养愿望
Adoptive Expectation

 

递交文件时间
Submission Date of Application

 

*填表须知见背面

(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 theHealth Statuscolumn, 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 theMarital Statuscolumn, 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 theChildren at Homecolumn, 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 theCriminal Punishmentcolumn, 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.

 
Editor: Chen Feng
Source: China-ccaa.org