U.S. Diversity Visa Lottery Entry Form

[FrontPage Save Results Component]

Your last (family) name:

First name:

Middle name:

Your birth date:

Your place of birth:

Mailing address:

street number city state/province country postal codes

If you are married, please fill in information about your spouse/children.

Last name:

First name:

Middle name:

Her/his Birthdate:

Her/his Place of Birth:

Her/his mailing address:

           street number, city state/province country postal codes

Your child's last name:

First name:

Middle name:

Her/his birth date:

Her/his place of birth:

Her/his mailing address:

 Full name (last, first), date of birth, City, Country of birth.

Your other children's info (full name, dates of birth and places of birth): Full name (last, first), date of birth, City, Country of birth. Name (last, first), date of birth, city, country of birth Name (last, first), date of birth, city, country of birth Name (last, first), date of birth, city, country of birth

Your Signature:

 

Your Email: (To receive confirmation or other information via email)

Tel:

Fax:

Payment By:

Bank Draft Drawn On US Bank International Money Order VISA

Payable to: Xie Law Offices LLC.

Your notes to us:

 

Press "Print" on the top menu bar and print two copies of this form, then click "Send"!

NOTE: Print out two copies of this form , after you fill it out, before you click the "Send" buttom! One copy will be mailed to us after you sign it. You keep another copy for your record!

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

1. 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. Have you signed your name in the blank?

          3. Have you put the required processing fees into the envelop?            

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)

Only $80 U.S. dollars for two separate applications of a husband and wife. Two separate applications!

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. 

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

Xie Law Offices LLC,

5430 Jimmy Carter Blvd, Suite 230
Norcross, Georgia 30093

      U. S. A.

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