Please Complete and Return This Form to Us Along with Your Search Membership

Adoption Network Cleveland Search Questionnaire
for Adoptees in Search

Please complete and return this form to us along with your search membership. This information will help us to guide you in initiating/ completing your search.

______Copy of amended birth certificate (from after your adoption)

______Copy of original birth certificate (if you have it)

______Copy of non-identifying information from agency that handled your adoption

______Other:______

In what county, city and state were you born? ______

What was the name of the hospital? ______

In what county and state was your adoption finalized? ______

Were you named at birth? ______

If so, state name: ______

Any other details you know about your family member/s that may be helpful to us, such as

names, dates of birth, race, occupation, etc.:______

______

______

______

______

Please return to:

Traci Onders

Adoption Network Cleveland

4614 Prospect Avenue, Suite 550

Cleveland, Ohio 44103

Please call (216) 482-2313 with any questions.

Thank you for your membership. We look forward to working with you.