REGISTER WITH ASCME
PRINT IT OUT-FILL IT OUT AND MAIL
DATE__________________________________
NAME____________________________________________________________________
ADDRESS_________________________________________________________________
CITY_________________________________ STATE_______
ZIP__________________
PHONE - DAYS____________________________ NIGHTS_________________________
ADOPTEE______ BIRTHMOTHER______
BIRTHFATHER______ SIBLING____
ADOPTIVE PARENT______ OTHER_________________________________________
DATA ON PERSON TO BE FOUND
ADOPTED NAME___________________________________________________________
SEX____________ DOB_____________________________________
PLACE OF BIRTH__________________________________________________________
HOSPITAL_________________________________________________________________
PLACE OF ADOPTION______________________________________________________
AGENCY___________________________________________________________________
BIRTHFAMILY DATA
BIRTHMOTHER'S NAME@SURRENDER______________________________________
ADDRESS__________________________________________________________________
DOB__________________________________
SIBLING NAMES____________________________________________________________
DOB__________________________________
ADDITIIONAL INFORMATION
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
ASCME
c/o Peter Jensen
12 Smith St
South Portland ME 04106-2238