DIVERSITY
APPLICATION
|
PLACE PHOTO HERE. USE CLEAR TAPE. DO NOT STAPLE |
PLACE SPOUSE'S PHOTO HERE. USE CLEAR TAPE. DO NOT STAPLE |
PLACE CHILD'S PHOTO HERE. USE CLEAR TAPE. DO NOT STAPLE |
PLACE CHILD'S PHOTO HERE. USE CLEAR TAPE. DO NOT STAPLE |
PLACE CHILD'S PHOTO HERE. USE CLEAR TAPE. DO NOT STAPLE |
NAME (last, first, middle):
_________________________________________________________________
DATE OF BIRTH (day, month, year): ________________________________
PLACE OF BIRTH (city,
district/county, country)
_________________________________________________________________
NAME OF SPOUSE (last, first,
middle):
_________________________________________________________________
SPOUSE'S DATE OF BIRTH (day,
month, year):
_________________________________________________________________
SPOUSE'S PLACE OF BIRTH
(city, district/county, country)
_________________________________________________________________
CHILDREN:
Full
name
Date of
birth
Place of birth
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
CURRENT MAILING ADDRESS
(Street, City, District/County/Province, Country, Postal code):
_________________________________________________________________
TELEPHONE NUMBER (include
country code):
_________________________________________________________________
APPLICANT'S NATIVE COUNTRY
IF DIFFERENT FROM COUNTRY OF BIRTH:
_________________________________________________________________
U.S. CONSULATE TO ISSUE
VISA:
_________________________________________________________________
APPLICANT'S SIGNATURE:
_________________________________________________________________
*********
TO HIRE OUR LAW FIRM
Submit payment by credit card at http://www.myvisa.bigstep.com.
Complete this form, sign, and include photo.
Mail this application form to us:
Attn.: Green card lottery
National Immigration Services
18760 E. Amar Rd. #150
Walnut, Ca 91789