Form 3.28	Application for adoption order
Court Procedures Rules 2006
(see r 3156 (Adoption order—application))

In the Supreme Court of the Australian Capital Territory

No SC		of (year) (Court to complete)
Adoption Act 1993

In the adoption of (full name of child or young person)

Take notice that the Court will hear an application *[by/on behalf of] the proposed adoptive parent(s) on (date), at (time) (or as soon after that as this application can be heard), for the adoption of (full name of child or young person).
Particulars of proposed adoptive parent(s)
	Adoptive father	Adoptive mother	
Full name:			
Occupation:			
Address:			
Date of birth:			
Relationship (if any) to the child or young person:			

Particulars of the child or young person proposed to be adopted
Full name of child or young person:		
Sex:		
Date of birth:		
Place of birth:		
Name and any former names (in full) of father:		
Name and any former names (in full) of mother:		

This application is made—
*by the proposed adoptive parent(s).
*for the proposed adoptive parent(s) by (name), solicitor(s). 
*on behalf of the proposed adoptive parent(s) by *[the chief executive/(name), the principal officer of (name), a private adoption agency].
Supporting and accompanying material
This application is supported by the affidavit of (name of applicant(s)) *[sworn/affirmed] on (date).
This application is accompanied by:
(list the documents required to accompany the application (see r 3158)).
(the documents that you intend to rely on must be filed with the application (see r 3156))
Date:
(signature of applicant/applicant’s solicitor)
(name of applicant/applicant’s solicitor)
Address for service of documents
(set out applicant’s address for service)
(if represented by a solicitor the following information may be given)
*Document exchange box no:
(if postal address different from address for service)
*Postal address:
*Fax:
(if the applicant is not the chief executive, or the principal officer of a private adoption agency, the applicant must serve on the chief executive copies of the application, the affidavit under r 3157 supporting the application, and each document accompanying the application under r 3158)
*To:	The chief executive

*omit if, or whichever is, inapplicable
(If the name of a birth parent of the child or young person to be adopted is unknown to the proposed adoptive parent(s), care should be taken to ensure that this information is not disclosed to the proposed adoptive parent(s) in filling out this form.  In such a case, if practicable, this form should be filled out and signed by the solicitor(s) for the proposed adoptive parent(s), by the chief executive responsible for adoption or by the principal officer of the relevant adoption agency (as appropriate).)