| DV-2009
U.S. DIVERSITY VISA LOTTERY APPLICATION Enter information online before printing or Neatly PRINT all information in English. |
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Applicant's Last Name |
First Name |
Middle Name |
Date of Birth (Day/Month/Year) |
Place of Birth (City/Town, District/Province, Country) |
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Applicant's Native Country, ONLY if different from country of birth (see instructions below) |
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| Name, date and place of birth of the Applicant's Spouse | ||
Spouse Last Name |
First Name |
Middle Name |
Date of Birth (Day/Month/Year) |
Place of Birth (City/Town, District/Province, Country) |
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| Name, date and place of birth of the Applicant's Children | ||
Child 1 Last Name |
First Name |
Middle Name |
Date of Birth (Day/Month/Year) |
Place of Birth (City/Town, District/Province, Country) |
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Child 2 Last Name |
First Name |
Middle Name |
Date of Birth (Day/Month/year) |
Place of Birth (City/Town, District/Province, Country) |
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Child 3 Last Name |
First Name |
Middle Name |
Date of Birth (Day/Month/year) |
Place of Birth (City/Town, District/Province, Country) |
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| If you have more than 3 children list them on the back of the application | ||
| If I am selected, I hereby authorize you to notify me at the following address: | Votre adresse: |
VOTRE PHOTO ICI |
| Telephone: | ||
| Email: | ||
| Signature: | ____________________________________ |
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