Short Gestational Surrogate Applicant Questionnaire Preliminary Questions Your First Name * Your Last Name * Phone Number * Email Address * Are you between the ages of 21 and 40, or have had a recent birth (within past 4 years)? * Yes No Have you given birth to at least one child and are currently not pregnant? * Yes No Are you or your children receiving public assistance (includes Medicaid)? * Yes No Are you smoke and drug free? * Yes No Do you have a valid driver’s license? * Yes No Do you have access to a vehicle? * Yes No Do you reside in one of the following states? * Georgia South Carolina North Carolina Tennessee Alabama Other Are you a permanent US resident? * Yes No Do you speak English fluently? * Yes No How did you hear about us? * At this time, you do not meet the necessary qualifications. If any of the above information changes, please resubmit this form or contact us by phone or email. If you are human, leave this field blank.