DV 2004 Visa Lottery Entry Form
1. Full Name:
_____________,
Last First Middle
2. Date of Birth:
______________________________________________
Day Month Year
3. Place of Birth: ________________________________________________
City Province Country
4. Names, Birth Dates, and Places of Birth of Spouse and Child(ren):
Spouse:________________________________________________________________
Child:__________________________________________________________________
Child:__________________________________________________________________
Child:__________________________________________________________________
5. Mailing Address:
__________________________________________________________________
Street Apt. City
________________________________________________________________
Province Country
| 6. Signature:
7. Applicant's Native Country if Different than Country of Birth: _________________________________________ 8. Recent photograph (50mm x 50mm or 2 in.x2 in. ) passport photo size: |
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