ContactWhat is your interest in surrogacy? *HowToBeASurrogateMother.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?*YesNoAre you a permanent U.S. resident who does not live in Alaska, Hawaii, Louisiana, Michigan, Nebraska, or New York?*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?*YesNoHeight*feetinchesWeight*Have you taken anti-depressants/anxiety medication in the last 9 months?*YesNoIf you have had anti-depressant/anxiety medications in the last 12 months, please tell us the approximate last date you had it. Date Format: MM slash DD slash YYYY Your BMI is .American Surrogacy is not able to work with any surrogates who have a BMI under 19 or over 32 at this time. We follow American Society for Reproductive Medicine (ASRM) guidelines which have been established to protect the health of surrogates and newborns. To learn more about calculating your BMI please visit: www.nhlbi.nih.gov. If your circumstances change please feel free to submit an application again. Thank you for your interest in American Surrogacy!Thank you for your interest. However, based on American Society for Reproductive Medicine (ASRM) guidelines, at this time American Surrogacy is not accepting surrogates who have had anti-depressants/anxiety medications in the last 9 months. If your circumstances change, please re-submit your application.Thank 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 Do you need to be matched with Intended parents?*Yes, I need help matching.No, I am looking to be a gestational surrogate for a family member.No, I am looking to be a gestational surrogate for a friend.No, I am working to match on my own.Are you working with a fertility clinic?YesNoName* 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.Did you experience any complications during a past pregnancy?*YesNoPlease describe the complications you experienced.Have you been convicted of a felony?*YesNoIf you have had a tattoo/piercings done in the last 12 months, please tell us the approximate date it was done. Date Format: MM slash DD slash YYYY *By submitting this form, you are authorizing American Surrogacy to be provided with this information. Are you currently residing in the U.S.?YesNoAt this time, American Surrogacy can only serve U.S. residents.Contact me by:* Email Phone Mail Parent 1 (Required)Name* First Last Country of Citizenship*Gender*Please SelectFemaleMaleBirth Date* Date Format: MM slash DD slash YYYY Parent 2Name First Last Country of CitizenshipGenderPlease SelectFemaleMaleDate Date Format: MM slash DD slash YYYY If married, please enter date of marriage Date Format: MM slash DD slash YYYY Contact InfoEmail* Phone*Best Day/Time to Call*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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?*I need an egg donor.I need a sperm donor.I am already working with a fertility clinic.I have embryos.I am seeking guidance.Do you need help finding a gestational carrier?*YesNoSelect which describes your gestational carrier.*FamilyFriendOtherAdditional Comments*By submitting this form, you are authorizing American Surrogacy to be provided with this information.