PROBATE COURT OF WOOD COUNTY, OHIO David E. Woessner, Judge In the Matter of the Placement of:_______________________________________________________________________ (Child's Name After Adoption) Case No: ______________________ Date:____________________________ APPLICATION FOR PLACEMENT OF A CHILD TO BE ADOPTED (As per Section 5103.16 of the Ohio Revised Code) ADOPTING FATHER’S INFORMATION Name (Last, First, Middle) Birthdate Age Birthplace Current Address (Street, City, State, Zip Code) Education (Highest grade completed or degree earned) Race Ethnic Background Name of School/University Date Religious Denomination Occupation/Position Held Name and Address of Current Employer Social Security Number Length of Employment Name of Previous Employer (1) Dates of Employment Name of Previous Employer (2) Dates of Employment Current Marital Status: List List c Single Dates Married c Divorced c Places Termination Dates Physical Description: c Places Height: Widowed # Marriages # Divorces Full Name of Spouses of ALL Marriages How Terminated Weight: Full Name of Spouses of ALL Previous Marriages Hair: Eyes: Skin: Description of Personality: Describe personal interests, hobbies, group memberships American LegalNet, Inc. www.USCourtForms.com Crensch$\forms\19.4 9/18/02 ADOPTING MOTHER’S INFORMATION Name (Last, First, Middle) Birthdate Age Birthplace Current Address (Street, City, State, Zip Code) Education (Highest grade completed or degree earned) Race Ethnic Background Name of School/University Date Religious Denomination Occupation/Position Held Name and Address of Current Employer Social Security Number Length of Employment Name of Previous Employer (1) Dates of Employment Name of Previous Employer (2) Dates of Employment Current Marital Status: List c Single Dates List Married c Divorced c Places Termination Dates Physical Description: c Places Height: Widowed # Marriages # Divorces Full Name of Spouses of ALL Marriages How Terminated Weight: Full Name of Spouses of ALL Previous Marriages Hair: Eyes: Skin: Description of Personality: Describe personal interests, hobbies, group memberships Petitioner Petitioner ____________________________ Phone Number (include area code) ____________________________ Phone Number (include area code) American LegalNet, Inc. www.USCourtForms.com