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REGISTRATION FOR THE DIVERSITY
IMMIGRATION VISA PROGRAM (LOTTERY)

1.    APPLICANT'S FULL NAME:

____________________ ,
Last name
. . . . . . . . . . . . . . . . . . . . .
First name
. . . . . . . . . . . . . . . . . . . . .
Middle name
2.    APPLICANT'S DATE OF BIRTH:

Day:___________   Month: _______________   Year: ____________

3. NAME, DATE AND PLACE OF BIRTH OF APPLICANT'S SPOUSE AND CHILDREN, IF ANY.

 

SPOUSE'S NAME: _________________________

DATE OF BIRTH:__________________________

PLACE OF BIRTH:_________________________

 

CHILD'S NAME: __________________________

DATE OF BIRTH:__________________________

PLACE OF BIRTH:_________________________

 

CHILD'S NAME: __________________________

DATE OF BIRTH:__________________________

PLACE OF BIRTH:_________________________

 

CHILD'S NAME: __________________________

DATE OF BIRTH:__________________________

PLACE OF BIRTH:_________________________

 

CHILD'S NAME: __________________________

DATE OF BIRTH:__________________________

PLACE OF BIRTH:_________________________

 

CHILD'S NAME: __________________________

DATE OF BIRTH:__________________________

PLACE OF BIRTH:_________________________

 

4.    APPLICANT'S MAILING ADDRESS:

____________________________________________

____________________________________________

____________________________________________

 

PHONES:

_____________________________

_____________________________

_____________________________

 

4. APPLICANT'S NATIVE COUNTRY IF DIFFERENT FROM COUNTRY OF BIRTH:

____________________________________________

5. APPLICANT'S  2 inch x  2 inch PHOTOGRAPH IS ENCLOSED:

FOTO 2 x 2 inches
(50  x  50 mm)

Your full name and signature must
be on the back of the photograph.

 

7.    DATE: __________________    APPLICANT'S SIGNATURE: _____________________________