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?*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 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 or friend.No, I am working to match on my own.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*feetinchesWeight**By submitting this form, you are authorizing American Surrogacy to be provided with this information. 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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 DarrussalamBulgariaBurkina 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?*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 - I have a Gestational Surrogate (family member or friend).Getting started - I have a Gestational Surrogate (other).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. 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