綠卡樂透獎報名表U.S. Diversity Visa Lottery Entry Form

[FrontPage Save Results Component]
姓 Your last (family) name:
名 First name:
中間名 Middle name:
出生年月 日 Your birth date:
出生地Your place of birth:
通信地址 Mailing address:
配偶/子女情況 If you are married, please fill in information about your spouse/children.
配偶之姓 Last name:
配偶之名 First name:
配偶之中間名 Middle name:
配偶之出生年月日 Her/his Birthdate:
配偶之出生地 Her/his Place of Birth:
配偶之通信地址 Her/his mailing address:
          
子女之姓 Last name:
子女之名 First name:
子女之中間名 Middle name:
子女之Her/his birth date:
子女之出生年月日 Her/his place of birth:
子女之通信地址 Her/his mailing address:
其他子女的情況 Your other children's info (full name, dates of birth and places of birth):
本人簽名(印出再簽)  Your signature
 
電子信箱 Your Email: (To receive confirmation or other information via email)
電話 號碼 Tel:
電傳號碼 Fax:
付款方式 Payment By:

收款人Payable to: Xie Law Offices LLC.

有話對我們說 Your notes to us:

 

stop.wmf (2966 bytes) 先打印兩份﹐一份寄給我們另一份自己保存。Press "Print" on the top manu bar and print two copies of this form, then click "Send"! 然後按Send鍵

NOTE: Print this form out, after you fill it out, before you click the "Send" buttom!

Sign this form and mail it to us as soon as possible!  We ask:

1. 信封中放37mm乘37mm (1.5 inches乘1.5inches ) 像片了嗎﹖ Have you put a recent 37mm x 37mm (1.5 inches X 1.5 inches) photo (preferably less than 6 months old) in the envelop ?
2. 你簽名了嗎﹖Have you signed your name in the blank交   ?費用了嗎﹖
              3. Have you put the required processing fees into the envelop?            

單人申請﹕五十美金Our processing fee is only $50 U.S. dollars for an individual applicant. (Your application will be timely processed as soon as the processing fees are received)

夫婦申請﹕八十美金(須交兩份申請表)Only $80 U.S. dollars for two separate applications of a husband and wife.

郵寄憑據﹕一份 五美金 To receive an original official stamped "Certificate of Mailing" from the U.S. Post Office as proof of lottery submission,  please add $5 U.S. dollars for each application. 

郵寄地址Send the completed form and our processing fee to the following address:

Xie Law Offices LLC,
4803 Casa Loma Drive,
Atlanta, Georgia 30047
          U. S. A.
 

                    Any Questions? Contact us any time.   Thank you for choosing us!