ENTRY FORM - DIVERSITY VISA  (DV) LOTTERY 

FULL NAME :  __________________________________ (Last Name, Surname, or Family Name)

                            __________________________________ (First Name)

DATE OF BIRTH :  ________________________________ (Day, Month, Year (e.g., 12 November 1956)

PLACE OF BIRTH :   __________________________________ (City or Town )

                                       __________________________________ (District, County, or Province)

                                       __________________________________ (Country)

NATIVE COUNTRY (Only if different from country of birth) : ____________________________

Full Name :  ____________________________________ (Last Name, Surname, or Family Name)

                       ____________________________________ (First Name) 

Date of Birth : _______________________________________ (Day, Month, Year) 

Place of Birth : _______________________________________ (City or Town )

                            _______________________________________ ( District, County, or Province)

                            _______________________________________ (Country)

• INFORMATION ABOUT YOUR CHILDREN

 (Only list your children who are under the age of 21 and not married; attach additional sheets if necessary) :

_________________________ (Name)                        _________________________ (Date of Birth)

            __________________________________________ (Place of Birth)

_________________________ (Name)                        _________________________ ( Date of Birth)

            __________________________________________ (Place of Birth)

FULL MAILING ADDRESS :                                                                                  

SIGNATURE : _________________________________________________________

Copyright © 1999-2005 Edward Weiner, Attorney at Law.  All rights reserved.