To The Center of Adoption of Children

In the Ministry of Education of Ukraine

Ukraine, 252032, City of Kyiv,

Boulevard T. Shevchenko, #27

Husband’s Name

Wife’s Name

Citizenship Canadian

Home Address

Identification Document of Individuals

Passport, No., date of issue and Country

Applicant 1 Passport No.

Date of Issue

Country Canada

Applicant 2 Passport No.

Date of Issue

Country Canada





We, Last, First, Middle (Applicant 1), and Last, First, Middle, are formally requesting to be taken on as candidates for adoption by the Center for Adoption and are requesting them to provide us with permission to visit Government Children’s Orphanages, with the intent to select, meet and establish contact with prospective adoptive children. We would like to adopt ______ children, gender preference, within the age range of __________.


Date: October 1, 2000 Applicant 1 (Signature above) Applicant 2 (Signature above)