Re: U.S. Department of State Diversity Visa (DV) Lottery

Name:           _____________________________________________

Full Address: _____________________________________________

                     _____________________________________________

                     _____________________________________________

E-Mail:          _____________________________________________

Telephone (home): ________________________________________

Telephone (work): ________________________________________

Fax:              ______________________________________________

Check as appropriate :

()    I want to use Attorney Edward Weiner's office as my contact address for the lottery.

()    I'd rather use my own address as the contact address for the lottery

I am familiar with the requirements for the U.S. Department of State’s Diversity Immigrant Visa Program ("the lottery"), and the information I am providing in my registration is accurate and truthful.  Although Attorney Edward Weiner will make all reasonable efforts on my behalf, there is no guarantee of my lottery entry being selected.  While the U.S. Department of State does not charge any initial fee for submitting a lottery entry form, I agree to pay Attorney Edward Weiner the appropriate fees for his services in handling and submitting my entry form.  For my form to be submitted on time for this year’s lottery, Attorney Edward Weiner must receive my completed and signed form and photograph at least 1 week before the official deadline set by the Department of State.

I also understand that Attorney Edward Weiner’s services at this time will be limited to the handling and submission of my lottery entry form.  If my entry is among those selected, I may decide to retain Attorney Edward Weiner at a later date to assist with my application for an immigrant visa or adjustment of status.  Fees I pay for entry in the lottery will be credited towards any future fees charged by Attorney Edward Weiner.

I have fully read understood the contents of this agreement and accept these terms of limited representation.

Signature:        __________________________________

Date:                 __________________________________

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