ContactWhat is your interest in surrogacy? *Surrogate.com has partnered with surrogacy professional American Surrogacy. By submitting this form, you authorize a representative of American Surrogacy to be provided with this information. I am interested in becoming a surrogate. I am looking for a surrogate for my baby. Are you between the ages of 21 and 40?*YesNoHave you given birth to at least one child and are currently not pregnant?*YesNoAre you parenting at least one child in the home (the child must live with you)?*YesNoAre you on state assistance?*YesNoAre you on Medicaid?*YesNoAre you smoke and drug free?*YesNoAre you exposed to secondhand smoke?*YesNoDo you have a valid driver's license?*YesNoDo you have access to a vehicle?*YesNoAre you a permanent U.S. resident?*YesNoDo you speak English fluently?*YesNoThank you for your interest. At this time you do not meet the qualifications to become a surrogate at this time. If your situation changes that would alter your answers to the above questions, please visit us again and redo the form.I would like to receive information / be contacted by (check at least one)* Phone Mail Email Name* First Last Email Address* Phone*Best time to call*OK to text (SMS)?YesNoAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code *By providing an address, you will receive free information by mail.Height*feetinches Weight**By submitting this form, you are authorizing American Surrogacy to be provided with this information. This iframe contains the logic required to handle Ajax powered Gravity Forms. Contact me by:* Email Phone Mail Parent 1 (Required)Name* First Last Country of Citizenship*Gender*Please SelectFemaleMaleBirth Date* Parent 2Name First Last Country of CitizenshipGenderPlease SelectFemaleMaleDate If married, please enter date of marriage Contact InfoEmail* Phone*Best Day/Time to Call*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country How ready are you to begin the surrogacy process?*Still researching, but would like more information.Have researched surrogacy and would like to speak to a surrogacy specialist to find the best fit.Ready to begin the process and set up a consult.What can a surrogacy professional help you with?*Not sure - seeking guidance.An embryo with both egg and sperm donation and a Gestational Surrogate.An embryo with egg donation only and a Gestational Surrogate.An embryo with sperm donation and a Gestational Surrogate.A Gestational Surrogate only.Getting started - a Gestational Surrogate and donor/embryo are not needed.Are you already working with a fertility center?*YesNoAdditional Comments*By submitting this form, you are authorizing American Surrogacy to be provided with this information. This iframe contains the logic required to handle Ajax powered Gravity Forms.