Become a Surrogate

“The World’s Most Reputable and Successful Surrogate Program.”

Apply to Become a Surrogate

Please complete the Form below.

Once it is received you will be contacted regarding your acceptance as a surrogate.

To be considered a candidate for our program, you must meet the basic qualifications:

Must be 18-35 years old, a non-smoker, and less than 200 pounds.
Must be from the United States.
Must have previously had a child.
Cannot live in MI.

You can also contact us if you want to become an egg donor or to know how much do surrogate mothers get paid

How to become a Surrogate Mother:

This is a secure form and 100% private. We will not use any of this information for any other purpose than the required process to approve you as a surrogate mother.

Dear Potential Surrogate Mother:

Thank you for your interest in our program. If you would like the brochure that we typically send to surrogates, please let us know, and we will send it to you. Please follow these instructions carefully:

Complete the online application in its entirety. This is a lengthy application and should be completed in one sitting. Please allow plenty of time to carefully consider and answer each question.

Complete the online autobiographical questionnaire about you, your family, your spouse, etc. This is a form prepared by our psychologist and both you and your husband (or significant other if you are living with someone) need to fill it out separately.

Print and complete a medical records release form to be sent to whichever doctor(s) delivered your child(ren). It more than one doctor was involved, make a copy of this and give it to each doctor who would have your pregnancy records. DO NOT RETURN THIS FORM TO US. SEND IT TO YOUR DOCTOR.

Print and complete a criminal history release form to be delivered to your local law enforcement agency. DO NOT RETURN THIS FORM TO US. Take it or mail it to your local sheriff’s or police department. (You will need to download the 'Surrogate Application Part 2' form to complete steps 3)

Once I receive your application, I will review it and call you to go over it. I will also answer any questions you may have about the program. If you do not have a phone, you will need to call us from someone’s home a week after you’ve sent us the application. If you have not heard from us within a week, please contact us.

After the initial interview with me, I will draw up a profile sheet that summarizes the things the couples would want to know about you. That profile sheet is then shown to the couples that are looking for surrogates.

Once a couple indicates that they are interested in working with you, I will call you and give you the same type of information about the couple that I given them about you. You can decide if they sound like the type of people for whom you’d like to do this. If so, we will send your application to our psychologist, and he will call you to go over it and schedule a time for you to come here for the full psychological testing.

Because we have such an active surrogate program, it is important that you return the application as soon as possible. Please review the checklist included with this packet to make sure you’ve done everything we’ve asked. If you have any questions about any of this, feel free to call.

Thank you again for your interest in our program. You are about to become involved in a wonderfully rewarding experience, and you will be providing the most valuable gift imaginable to people who desperately want a child. We look forward to hearing from you.

Very Truly Yours,Steven C. Litz
To begin the application press the "Next" button below. (Reminder, please do not start this application unless you have adequate time to complete it)

TO ALL SURROGATES REGARDING HEALTH INSURANCE. AND EXPENSE REIMBURSEMENT

Health Insurance:

Because of some recent confusion over health insurance and how it applies to surrogacy, all potential applicants should read the following note carefully. Health insurance companies are in the business of making money. Pregnancy is expensive, and insurance companies do not like to pay for it. They like it even less in surrogate situations, but so long as their policies do not exempt surrogacy, they are legally obligated to pay for your pregnancy.

A few insurance companies have given us problems in this regard, so the first piece of advice is not to mention anything to your employer about the fact that you're thinking of being a surrogate. It's not that we're hiding anything from the insurance company; it's simply none of their business. If you became pregnant by your husband, they certainly wouldn't ask you who the father was, so why should that matter when the child is not his?

Secondly, and equally as important, if you currently have insurance you must use your own insurance to pay for your medical expenses. The reasons for this is that if you do not, then the couple would be required to take out a policy on you, and the application you would fill out would ask if you had insurance in force already. If you say that you do, then the new policy would apply only after the first one paid your bills. If you say that you don't, then you're lying and you'd be liable for fraud. So, if you do have insurance, but you do not want it to be used, DO NOT APPLY TO OUR PROGRAM.

Expense Reimbursement:

As mentioned to you when you first called in, the couple pays for all of your travel expenses. They also will pay for your husband's travel when you come to Indianapolis to be screened psychologically, and when you travel to one of the cities for the initial screening for the AI or embryo transfer program (if you are involved with that program). For the actual nseminations and/or embryo transfers, your husband's presence is NOT required, and the couple will not pay for his travel. If you want him (or anyone else) to accompany you, that is fine, but it will be at your expense.

Also, while you are traveling, you get $100/day for your travel. This covers your meals, your and your husband's lost wages, and your childcare. These things are not reimbursed because requiring you to keep receipts and submit them to us was too much of a problem. So, you get a flat $100/day. So, for example, if you and your husband (if you are married) come here Friday night, and leave Sunday, you would be reimbursed $200.

Finally, should any of you wish to speak to other surrogates, we will be providing you with the names and phone numbers of dozens of women from across the country. Once you are accepted into the program, we will reimburse you for calls to any of these women, up to $10/month. Calls you make to your couple are always reimbursed, so long as they are not excessive (we had one surrogate who called her couple 25 times in one day).

BEFORE YOU COMPLETE THIS APPLICATION, PLEASE READ THE FOLLOWING IMPORTANT NOTICE AND SIGN THE STATEMENT THAT FOLLOWS IT. IF YOU CANNOT HONESTLY SIGN THIS, PLEASE DO NOT COMPLETE THE APPLICATION.

Important Notice:

Recently we have had several surrogates who, after they applied and were accepted into our program, and were selected by our clients, decided that they really couldn’t participate in the program. This is devastating for our clients, embarrassing for us at SMI, and costly for our surrogates. Please complete this application only if you are ready now to be a surrogate if called upon by SMI and only if you can honestly respond "I agree" the statement below. It would be unkind and upsetting to our clients if you were to withdraw your application after they reviewed it and became hopeful about working with you.

Statement: I am ready now to be a surrogate if called upon by SMI. I understand that it would be unkind and upsetting to the people seeking to become parents if I were to withdraw my application after they reviewed it and became hopeful about working with me.

(Agree or disagree with these statements by checking one of the boxes below.)

I Agree I Disagree

The "I’m Ready to be a Surrogate" Checklist

Lately, here at SMI we’ve had several surrogates who were selected, came to Indianapolis to be screened, then backed out of the program immediately after they were here. They gave a variety of reasons, but whatever they said didn’t matter. It was expensive for them, it was devastating for my clients, and it reflects poorly on my program. So, we’ve created this checklist for you to be absolutely sure that you are committed to doing this. We will invest a huge amount of time and money in you, and we do not want you to be a surrogate in our program unless you know that you are ready to proceed. With that in mind, please review every one of these statements, and check each one to make sure that you are willing to give the most wonderful gift in the world to our clients (and please note that every one of these situations has actually happened, however ridiculous it may seem).

Review every one of these statements, and check each one to make sure that you are willing to give the most wonderful gift in the world to our clients.

I understand that I may be away from my child(ren) for several days. I will be able to make arrangements for someone responsible to watch them while I’m gone. I know I can’t bring them with me to Indianapolis for the psychological screening, or to the clinic for the medical procedures. I can’t ask the doctor to watch them for me. I can’t fly home to check on them, then fly back for the medical procedures. I’m strong enough that even though I’ll miss my kids I’ll still be able to be a surrogate. If I’m married or involved with someone, my partner completely supports my decision to do this. My partner won’t leave me because I want to be a surrogate. My partner isn’t (as far as I know) going to sleep with someone else just because I get pregnant. He/she isn’t going to be transferred overseas for his job in the next couple of months, forcing me to go with him. My partner is as enthusiastic about me being a surrogate as I am. I understand that if I’m using birth control now, I’ll have to stop. I understand this means that I need to be extra careful if I’m sexually active that I don’t get pregnant on my own. I realize that the best way to guarantee this is not to have intercourse while I’m a surrogate, or at least until I’m pregnant through SMI’s program. If I’m in the embryo transfer program, I may be given certain medication which, depending on my cycle and how easy or difficult it is to regulate, I may be on for several months. If I’m going to be an egg donor, I understand that I’ll be given a drug called Pergonal which is a very powerful medication that will increase the production of my eggs. The drugs I’ll be given may have certain side effects, may make me feel grumpy, may give me certain infections, and may—in extremely rare instances—kill me (that’s never come close to happening in SMI’s program). Since I’m an adult, I know that I have the ability to research any of these drugs and ask the doctors questions about them. If I’m nursing my child, I understand that I’ll have to stop in order to be a surrogate. Some of the medicine I may take may be required to be injected. I’m not so terrified of getting a shot that I couldn’t be a surrogate. If I’m working, I realize that I’ll have to adjust my work schedule to accommodate surrogacy. That may mean that I have to take days off, or rearrange my hours. My schedule is flexible enough to do that. have no plans to move to New York, Michigan, or Washington DC (the 3 states where surrogacy is illegal), and I understand that once I sign a contract with the couple, I cannot move there. I AGREE THAT IF I FAIL TO FOLLOW THROUGH WITH AN APPOINTMENT OR I DROP OUT OF THE PROGRAM FOR ANY REASON AT ALL ONCE MY APPLICATION HAS BEEN REFERRED TO SMI'S PSYCHOLOGIST, OR AFTER I’VE BEEN SCREENED PSYCHOLOGICALLY, I’LL PAY EVERYTHING THAT’S BEEN SPENT ON MY BEHALF BACK TO SMI IMMEDIATELY.

Please complete and submit this application. Failure to respond to portions of the questionnaire or false answers will automatically eliminate you from the program. Please read the supplied information before answering these questions. Thank you.

I am interested in being:*

a surrogate only in the artificial insemination program, AND BY CHECKING THIS BOX I ACKNOWLEDGE THAT I HAVE HAD AT LEAST ONE CHILD MYSELF a surrogate only in the IVF/embryo transfer program, AND BY CHECKING THIS BOX I ACKNOWLEDGE THAT I HAVE HAD AT LEAST ONE CHILD MYSELF an egg donor only a surrogate or an egg donor In any of the programs, AND BY CHECKING THIS BOX I ACKNOWLEDGE THAT I HAVE HAD AT LEAST ONE CHILD MYSELF

I will be a surrogate for:*

a straight couple only a straight single man a gay couple or a gay single man any of these

First Name

Last Name

Phone

Address

City

State

Zip Code

Country

SSN#

Age (Must Be Between 18 - 35)

Birthday

Race

Height

Eye Color

Hair

Blood

Upload two good pictures of you and your family. If you have difficulty uploading the pictures, you can email them to scl@surrogatemothers.com.

Upload Pictures 1

Upload Pictures 2

Occupation

Employer's Name, Address, and Phone Number:

Annual Income

Marital Status

Date of Present Marriage

If you are Married, What was your Maiden Name

Date(s) of Prior Marriage(s) and Divorce(s) for you and your husband:

Husband's Names

Husband's DOB

Husband's SSN#

Husband's Blood Type

Husband's Annual Income

Husband's Occupation and his Employer

Number of Pregnancies

Number of Children

Child #1: Name, Age, Height, Weight, Eyes, Hair, Birth Weight

Child #2: Name, Age, Height, Weight, Eyes, Hair, Birth Weight

Child #3: Name, Age, Height, Weight, Eyes, Hair, Birth Weight

Child #4: Name, Age, Height, Weight, Eyes, Hair, Birth Weight

Child #5: Name, Age, Height, Weight, Eyes, Hair, Birth Weight

EDUCATION: Please list all schools attended and degrees received, beginning with high school

Child #1: Name of School, Dates Attended, Did You Graduate, Degree Received

Child #2: Name of School, Dates Attended, Did You Graduate, Degree Received

Child #3: Name of School, Dates Attended, Did You Graduate, Degree Received

Child #4: Name of School, Dates Attended, Did You Graduate, Degree Received

Child #5: Name of School, Dates Attended, Did You Graduate, Degree Received

MEDICAL/SOCIAL HISTORY: Please answer the following questions to the best of your ability. If any questions are answered "yes," give a complete explanation at the end of this section

Have you, your children, or anyone in your family ever had any of the following:

A. Seizures, fainting spells, paralysis, nervous or mental disorders, dizziness, or any other disorder of the heart or blood vessels?

Yes No

B. Asthma, emphysema, shortness of breath, chronic cough, or any other disorder of the lungs?

Yes No

C. Frequent or recurrent abdominal pain, bleeding from or disease of the stomach, intestines, gallbladder, or liver, indigestion, ulcers, diarrhea, or colitis?

Yes No

D. Sugar, protein, or blood in the urine; kidney stone or any other disorder of the kidneys, bladder, or prostate?

Yes No

E-1. Any disorder of the uterus or ovaries, any venereal disease, or any type of complications during or as a result of pregnancy?

Yes No

E-2. Have you ever had a C-section, or any other difficult with pregnancy?

Yes No

E-3. Have you ever had a miscarriage or stillbirth?

Yes No

F. Diabetes, thyroid, or other glandular disorder?

Yes No

G. Arthritis, bursitis, sciatica, gout, recurrent back pain, or any disorder of the back, spine, muscles, bones, or joints?

Yes No

H. Disorder of the eyes, ears, nose, or throat?

Yes No

I. Cyst, tumor, cancer, or blood disorder?

Yes No

J. Disorder of the skin, lymph system, or breasts?

Yes No

K. Any physical deformity or defect?

Yes No

L. Any disease not previously covered (other than minor childhood diseases)?

Yes No

M. Have you or your husband ever had marital problems? Have either of you ever seen a psychologist or other mental health counselor? (If so, when and why)

Yes No

N. Do you want more children of your own? (If so, how many, and when would you like more?)

Yes No

O. Do you own a major credit card?

Yes No

P. Have you ever had an abortion?

Yes No

Q. Had a check-up, consultation, illness, or surgery?

Yes No

R. Been treated or evaluated at a hospital, clinic or other medical facility?

Yes No

S. Had an EKG, x-ray, or other diagnostic test?

Yes No

T. Been advised to have any medical test or surgery and not followed such advice?

Yes No

U. Do you (or your husband) smoke cigarettes or have done so within the past year?

Yes No

V. Did you smoke while you were pregnant?

Yes No

W. Are you currently taking any prescribed medicines?

Yes No

X. Have you ever been advised to limit your use of alcohol or other addictive substances?

Yes No

Y. Do you drink coffee?

Yes No

Z. Have you ever been treated for or told to seek treatment because of alcohol or drug abuse, or any other chemical dependency?

Yes No

AA. Do you exercise? If so, how and how often?

Yes No

BB. Has any member of your immediate family ever had diabeters, cancer, stroke, high blood pressure or any type of heart disease? If so, identify each person, condition, and age or age at death.

Yes No

CC. Have either of your parents passed away? If so, please list the cause and date of death on the next page.

Yes No

DD. Have you, your husband, or any of your children been charged with or convicted of any crime (other than minor traffic offenses)?

Yes No

EE-1. Do you have or are you covered by medical insurance?

Yes No

EE-2. Does your insurance cover pregnancy?

Yes No

FF-1. Are you currently using any type of birth control, or have you ever had a tubal ligation, or has your husband had a vasectomy?

Yes No

FF-2. Have you ever used Depo-Provera or been on The Pill in the past year?

Yes No

GG. Have you (or your husband, if married) ever declared bankruptcy?

Yes No

HH. Have you ever applied to any other surrogate program, or do you now have an application pending with any other program?

Yes No

II. Which best describes your cycles:

Perfectly regular, like clockwork Very regular, I know when I'm ovulating Pretty regular, normally 28-30 days It varies, sometimes 28 days, sometimes several days shorter or longer I'm not sure what my cycle is like

JJ. Have you ever used marijuana, cocaine, crank, or any other controlled substance? If so, when was the last time, how often did you use it, and what drug did you use?

Yes No

KK. If you were to be given a urine screen today, would you test negative? If not, what would you test positive for?

Yes No

LL. Do you have any children who have ever lived with someone other than you? If so, please state who they are, where they lived and when, and the reason that they lived elsewhere.

Yes No

During The past MONTH, have you OFTEN been bothered by...

1. Stomach pain

Yes No

2. Back pain

Yes No

3. Pain in your arms, legs, knees, hips

Yes No

4. Menstrual pain or problems

Yes No

5. Pain or problems during intercourse

Yes No

6. Headaches

Yes No

7. Chest pain

Yes No

8. Dizziness

Yes No

9. Fainting spells

Yes No

10. Feeling your heart pound or race

Yes No

11. Shortness of breath

Yes No

12. Constipation, loose bowels, or diarrhea

Yes No

13. Nausea, gas, or indigestion

Yes No

14. Feeling tired or having low energy

Yes No

15. Trouble sleeping

Yes No

16. The thought that you may have a serious undiagnosed disease

Yes No

17. Your eating being out of control

Yes No

18. Little interest or pleasure in doing things

Yes No

19. Feeling down, depressed, or hopeless

Yes No

20. "Nerves" of feeling anxious or on edge

Yes No

21. Worrying a lot about different things

Yes No

22. Have you had an anxiety attack (suddenly feeling fear or panic

Yes No

23. Have you thought you should cut down on your drinking of alochol

Yes No

24. Has anyone complained about your drinking

Yes No

25. Have you felt guilty about how much you drink

Yes No

26. Was there ever a single day in which you had 5 or more drinks of beer, wine, or liquor

Yes No

27. Have you used marijuana or any other non-prescribed drug

Yes No

How long did it take you to become pregnant with each of your children?

When was your last menstrual period, and how long did it last?

Note: if you are not on the pill or using Norplant, you will need to keep track of your temperature, and we will send you the forms after we receive your application. After you have completed one month of charting, make a copy of the chart, and send it to us.

Are you adopted, or do you know anyone who is? Have you ever placed a child for adoption?

What were your feelings during your prior pregnancy (pregnancies)

Do you have any objections to abortion? If so, would you still be willing to terminate a pregnancy if asked to do so?

REFERENCES: Please list the names, addresses, and phone numbers of three (3) people other than family members who have known you for at least 5 years. Please discuss your participation in our program with them, so that when we contact them, they will know why we're calling.

Reference #1:

Reference #2:

Reference #3:

DOCTORS' NAMES: Please list the names, addresses, and phone numbers of your current physician.

Doctor's names, address, and phone number

Explain why you wish to be a surrogate.

Fee Arrangement: Our typical fee for first time surrogates is $15,000; in the event of multiple births it is increased to $20,000.

Is this acceptable to you?

Yes No

If 'No', what fee would you request. Please explain your reasoning if requesting a different fee.

AUTOBIOGRAPHICAL QUESTIONNAIRE:

These questions should be answered by both the surrogate applicant and her husband (or significant other if not married but living with someone), meaning that each of you must fill out this separately.

After you complete the entire application, you husband will have the opportunity to answer this portion as well. You will be provided a link to access that page, which your husband can answer as soon as you are finished.

Please try to answer the questions as completely and accurately as possible. The more you can tell us about yourself and your family, the better we will be able to evaluate you, and the better your chances will be of getting selected.

1-a. Where were you born? How big a town was it? Did you grow up mainly in this town? If not, please give a history of the moves your family made including the dates and places where you moved.

1-b. please give a summary of your ethnic background.

2. What memories of your childhood do you have? Are there any that are particularly painful or wonderful?

3. What are your biological parents' names, ages, occupations, and marital status? If they are married, how long have they been married? If either has passed away, please state when and cause of death

4. If they aren't married, when were they divorced? How did that affect you?

5. Where do your parents live now? How often do you see them?

6. How well did you get along with them while you were growing up? How well do you get along with them now?

7. Did your parents get along with each other? Did your family as a whole get along? If not, why not?

8. If your parents are divorced, have either remarried? If so, when?

9. If you have stepparents, what are their names, ages, and occupations?

10. How well did you get along with either of them growing up? Where do they live now? How often do you see them?

11-a. How many brothers and/or sisters do you have ? What are their names, ages, and occupations? Where do they live? Are they married? Children? How well did you get along with him/her growing up?

11-b. Please answer the question regarding any step-sisters or step-brothers. (If you included them in your previous answer, please indicate that relationship).

12. Is there anyone who has been particularly influential in your life? Tell me about them and how they have been important to you.

13. When do you see your family members? Do you enjoy spending time with your parents/brothers/sisters? If not, why not?

BECAUSE OF RECENT PROBLEMS WITH FAMILY MEMBERS OBJECTING TO SURROGACY, YOU ARE NOW REQUIRED TO DISCUSS YOUR PARTICIPATION IN THE PROGRAM WITH BOTH YOUR AND YOUR SPOUSE'S FAMILY. DO NOT SUBMIT THIS APPLICATION UNTIL YOU HAVE DONE SO.

14. What were the various people's reactions when you told them what you were doing?

15. What was your religious/spiritual upbringing? What do you think is the meaning of life? What do you see as your role in this world?

16. Do you attend church now? If so, which one? Does your spouse and/or children also attend?

17-a. Tell me about your high school experience. Did you enjoy it? Did you attend all your high school years at one school? If not, how many?

17-b. What was your grade point average? Did you graduate? If so, when? If not, why not?

18. What kinds of extracurricular activity did you participate in?

19. Did you work while in high school? If so, what kinds of jobs did you have? How many hours did you work each week?8

20. Did you date during high school? Frequently or one person for a long time?

21. Did you attend any type of school after high school? If so, where? Did you graduate? If not, why not? What was your grade point average? Did you enjoy your post-high school experience? Why?

22. What kinds of extracurricular activity did you participate in?

23. Tell me about any jobs you've had since high school. What did you do, how many hours, why did you leave, etc.? What did you like or dislike about it?

24. Did you date during college? Frequently or one person for a long time?

25-a. If you are currently employed, tell me about your job. Do you see yourself staying at this position long? What do you want to achieve at your present job? If you are planning to leave, why?

25-b. What are your career goals?

26. What have you achieved in life? Learned? Accomplished? What are you most proud of? What are you least proud of? Why?

27. Has there been any particular event or experience in your life that has had a significant effect on you? What happened?

28. Tell me about your spouse or significant other. Where did you meet? What attracted you to him/her? How long did you date prior to living together/getting married?

29. If the relationship ended, tell me when and why. For any subsequent relationships you have had, please provide the same information as in question.

30. How many times have you been pregnant? How many live births have you had? Miscarriages? Abortions?

31. How many children do you have? Tell me their names, ages, who their biological father is/are, and whether your child has any significant health problems or genetic diseases or deformities.

32. Tell me about your experience of being a parent. Do you enjoy it? How much time do you spend with your children? How do you spend time with them? What are your goals for your children?

33. Have you ever placed a child for adoption? If so, when and why? What was your emotional reaction to it? Have your feelings changed over the years?

34. Have you ever lost anyone close to you? Who? How did you deal with your loss?

35. Are you adopted? Do you know anyone who is? Do you think this has affected your decision to be a surrogate?

36. Do you know anyone who has had fertility problems? If so, please describe their difficulties.

37. Have you or your spouse ever been in counseling of any kind? If so, when and why? What was the outcome from your viewpoint?

38. Other than minor traffic offenses, have you ever been arrested or convicted of any crime? If so, what offense, and when.

39. What would you say is your best quality? Your worst? Your spouse’s best and worst qualities?

40. What would you say is your best quality? Your worst? Your spouse’s best and worst qualities?

BE SURE TO INCLUDE 2 RECENT PICTURES OF YOURSELF AND YOUR CHILDREN (IF YOU HAVE ANY) WITH THIS APPLICATION.

AGREEMENT

By filling out the enclosed application, returning it to Surrogate Mothers, Inc. ("SMI"), and upon notification that a couple is interested in working with me, I (meaning both myself and my husband if I am married) agree that:

1. If at any time within one year after the interview with the psychologist, I withdraw from the program for any reason without the couple's consent, I will refund to SMI the actual expenses incurred by the couple or by SMI on my behalf (for example, psychological screening, travel and lodging expenses, daily allowances, etc.), within ten (10) days after the attorney for the couple notifies me what those actual expenses are.

2. If at any time after a couple selects me to act as a surrogate mother (as described by the contract between the surrogate and the biological father or the couple), I become pregnant by any means other than by being artificially inseminated with the sperm from the biological father (or through artificial insemination with donor sperm if both the husband and the wife of the couple are infertile), or by having a successful embryo transplant, I will refund to SMI the actual costs incurred by the couple or SMI on my behalf up to the point that I became pregnant and notified the attorney for the couple of the pregnancy in writing.

3. If at any time after I have been screened psychologically and accepted into the program, I desire my own attorney, I am entitled to such representation, and I will be reimbursed up to $300 (or more if agreed upon in advance) for such representation.

4. If at any time after I have traveled to Indianapolis for psychological testing, it becomes apparent that I have misrepresented or lied about anything on the application or have not been truthful with the psychologist, I will be immediately rejected from the program, and the reimbursement provisions contained in Section 1 above shall apply.

6. I agree that attorneys fees are recoverable in the event of a lawsuit to enforce this agreement, that jurisdiction in the event of a lawsuit will be in the courts of Indiana, and that venue will be in Morgan County, Indiana.

7. I have read the above provisions, and by entering my initials below, I acknowledge that I understand the consequences of this agreement.

Your Initials:

Today's Date:

To complete this portion of the application press the "Submit" button below.

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888-787-7642