ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY
AND REQUEST FOR ADOPTION SERVICES

My/our signature(s) below signifies that I/we have read and understand the FEES AND SERVICES AGREEMENT, FEE SCHEDULE and EXPLANATION OF FEE SCHEDULE and agree to abide by these policies and procedures.

This Agreement comes into effect on the date signed by the applicants and will terminate when an adoption is finalized through Jewels For Jesus Adoption Agency. It may be revoked at any time by either party through the provision of written notice and the fulfilment of all financial obligations.

 

 

Signature

 

Date (mm/dd/yyyy)

 

 

Signature

 

Date (mm/dd/yyyy)

Please print name, address, phone number and email address below:

NAME (Applicant): 

NAME (Co-Applicant): 

ADDRESS: 

CITY: 

PROV: 

POSTAL CODE: 

PHONE (home): 

Cell: 

EMAIL: 

 

RETURN TO:

JEWELS FOR JESUS ADOPTION AGENCY INC.
6655 KITIMAT ROAD, UNIT 5
MISSISSAUGA, ON  L5N 6J4