NAME OF ADOPTEE LAST FIRST MIDDLE DATE OF BIRTH PHONE NUMBER OTHER PHONE NUMBER / / ( ) ( ) E-MAIL ADDRESS OR OTHER CONTACT INFORMATION HOME ADDRESS: STREET CITY STATE ZIP CODE MAILING ADDRESS: STREET (IF DIFFFERENT) CITY STATE ZIP CODE I WISH TO CONTACT: BIRTH MOTHER BIRTH FATHER SISTER BROTHER GRANDPARENT AUNT UNCLE OR OTHER RELATIVE AS NOTED: ADOPTION INFORMATION LAST NAME OF ADOPTIVE PARENT #1 FIRST MIDDLE LAST NAME OF ADOPTIVE PARENT #2 FIRST MIDDLE NAME OF ADOPTION AGENCY THAT HANDLED THE ADOPTION BIRTH PARENT'S NAME AND INFORMATION (IF KNOWN) LAST NAME OF BIRTH PARENT #1 FIRST MIDDLE LAST NAME OF BIRTH PARENT #2 FIRST MIDDLE State of County of Subscribed and sworn to before me this day of , 20 byPrint Name of Applicant Signature of Notary PublicRevised Bjh IT IS MY RESPONSIBILITY TO KEEP THE ADOPTION REUNION REGISTRY CURRENT AS TO ANY CHANGES: ADDRESS, NAME CHANGE, PHONE NUMBER ETC. STATE CITY CANNOT BE MADE UNLESS THE OTHER PERSON(S) HAS ALSO COMPLETED AN APPLICATION. I UNDERSTAND THAT THE INFORMATION PROVIDED ON THIS GENDER MALE FEMALE GENDER MALE FEMALE IF I WISH TO WITHDRAW THIS APPLICATION AT ANY TIME, I MUST NOTIFY THE ADOPTION REUNION REGISTRY IN WRITING BY SUBMITTING A CHANGE FORM. APPLICATION WILL BE SHARED WITH THE PERSON(S) INDICATED ABOVE.DATE(Notary Stamp) WHEN I PROVIDE NEW INFORMATION TO THE ADOPTION REUNION REGISTRY, THEY ARE AUTHORIZED TO UPDATE MY APPLICATION AS NECESSARY. GENDER MALE FEMALE GENDER MALE FEMALE GENDER MALE FEMALE (MUST BE 18 YEARS OLD OR OLDER) I AM INTERESTED IN MAKING CONTACT WITH THE PERSON(S) INDICATED ABOVE: BIRTH MOTHER, BIRTH FATHER, SIBLING(S), ADOPTIVE PARENT(S) AND/OR OTHER RELATIVES INCLUDING UNCLES/AUNTS, NEPHEWS/NIECES, GREAT-GRANDPARENTS AND GREAT GRANDCHILDREN (AS NOTED) AND I UNDERSTAND THAT CONTACT ADOPTEE APPLICATION Please Print Clearly MAIDEN OR OTHER NAMES USED DIVISION OF CHILD AND FAMILY SERVICESADOPTION REUNION REGISTRY Return to: NEVADA DIVISION OF CHILD & FAMILY SERVICES ADOPTION REUNION REGISTRY4126 TECHNOLOGY WAY, 3RD FLOORCARSON CITY, NEVADA 89706 American LegalNet, Inc. www.FormsWorkFlow.com