Gestational Surrogate Applicant Questionnaire If you are human, leave this field blank. 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 Florida 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.