DV-2009 U.S. DIVERSITY VISA LOTTERY APPLICATION
Enter information online before printing or Neatly PRINT all information in English.

Applicant's Last Name
First Name
Middle Name

Date of Birth (Day/Month/Year)
Place of Birth (City/Town, District/Province, Country)

Applicant's Native Country, ONLY if different from country of birth (see instructions below)
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)
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)

Child 2 Last Name
First Name
Middle Name

Date of Birth (Day/Month/year)
Place of Birth (City/Town, District/Province, Country)

Child 3 Last Name
First Name
Middle Name

Date of Birth (Day/Month/year)
Place of Birth (City/Town, District/Province, Country)
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:

c/o  

 Complete Mailing Address:

 ATTACH YOUR PHOTO HERE
(Use Clear Tape)
SIZE 1.5" X 1.5"
(37 mm x 37 mm)
B/W or color.
PRINT YOUR NAME ON BACK OF PHOTO.
Telephone:
Signature:
____________________________________
ENTRY FORM INSTRUCTIONS
Follow these instructions carefully to complete the Entry Form.
Type or PRINT neatly and clearly in English.
1- Applicant's Full Name: Last Name (surname/family), First Name and Middle Name 
2- Applicant's Date and Place of Birth:  Day, Month, Year -- Example: 14 May 1948. 
Place of birth: City/Town, District/Province, Country -- Example: Munich, Bavaria, Germany.
The name of the country should be that which is currently in use for the place where the applicant was born (Slovenia, rather than Yugoslavia; Russia rather than Soviet Union, for example).
3- Applicant's "Native Country", if different from country of birth:  If the applicant is claiming nativity in a country other than his or her place of birth, list that country. It can be (1) your spouse's country of birth, or (2) your mother's or father's country of birth, if you were born in a country of which neither was a resident or native.
4- Name, Date and Place of Birth of Applicant's Spouse:  List your Wife or Husband (if any).
5- Name, Date and Place of Birth of Applicant's Children:  List your unmarried children under 21 (if any). Unmarried children under 21 may be included on each of their parents' application forms. All children over 21 years of age must file separate applications.
6- Applicant's Mailing Address: Give the mailing address where we should notify you if you are selected, and/or to send you further information. 
7- Applicant's Signature: The applicant must sign the application using his/her normal signature. 
8- Photograph: Include a recent "passport style" photograph (1-1/2" x 1-1/2") color or black & white with your name written on the back.
  • Photograph dimension should be 1-1/2" x 1-1/2" inches or 37mm x 37mm.
  • Photograph must have been taken recently.
  • Photograph must have your name printed on the back. 
  • Attach your photo to the Entry Form (clear tape is best)

9- Enclose payment.

FEE: (Check one) __ U.S.$50 for myself __ U.S.$80 for myself and family

Payment enclosed in (Check one):
___ U.S. Dollars cash
___ U.S. Check
___ U.S. Money Order or Cashier's Check
___ International Money Order
___ International Bank Draft
___ Western Union
___ Federal Express

(NOTE: Make checks payable to: New Americans)
Mail your Signed Entry Form, Photograph, Processing fee, and this
Instruction Sheet with the payment information, to the following address: 

Please Do NOT fax this FORM; we need the signed Form with photo.

  
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