GREEN CARD LOTTERY

                  (DV-2005)


NOVEMBER 1, 2003 AND TUESDAY, DECEMBER 30, 2003



1. FULL NAME [Last, First, Middle]

2. DATE OF BIRTH [ Day, Month, Year]

3. GENDER [Male or Female]

4. CITY/TOWN OF BIRTH
 
5. COUNTRY OF BIRTH

6. APPLICANT PHOTOGRAPH [ 2" x 2" ] JPG FORMAT  light colored background *1
 
7.  MAILING ADDRESS [City/Town, District/Country/Province/State, Postal Code/Zip Code, Country]

8. PHONE NUMBER
 
9.  E-MAIL ADDRESS

10. COUNTRY OF ELIGIBILITY  [If the appicants country is different from cuntry of birth]

11. MARRIAGE STATUS   [Yes / No]


12.  NUMBER OF CHILDREN  [Unmarried and 21 years of age]

13. SPOUSE INFORMATION [ Name, DOB, Gender, City/Town of Birth, Country of Birth, Photograph ]


14. CHILDREN INFORMATION  [Name, Date of Birth, Gender, City/Town of Birth, Country of Birth, Photograph]

15. EDUCATIN / EXPERIENCE  [High school - 12 years or 2 years job experience required ]

Please Click send button once.