DV-2004 Green Card Lottery Application Form

(If you wish our office to process your Application for DV-2004, please complete the applicable fields below:)

Full Name (First/Middle/Last) :
E-mail Address:
Date of Birth: (DD/MM/YYYY)

Birth Place (City/District/Country):
Applicant's Native Country if Different from Country of Birth:

Current Address:
City/Town:
State/Prov.: Post./Zip Code:
Country:

Phone Number:

Children/Spouse Applying with you if any:
Dependent 1: Date of Birth(DD/MM/YYYY):
Birth Place (City/District/Country):

Dependent 2: Date of Birth(DD/MM/YYYY):
Birth Place (City/District/Country):

Dependent 3: Date of Birth(DD/MM/YYYY):
Birth Place (City/District/Country):

Dependent 4: Date of Birth(DD/MM/YYYY):
Birth Place (City/District/Country):

Dependent 5: Date of Birth(DD/MM/YYYY):
Birth Place (City/District/Country):

Mode of Payment: (US $50 ; $75 for family of two(2) )
  Credit

Visa    Mastercard    American Express

Credit Card     Expiration Date(MM/YYYY)

  Check (to be mailed)

  Money Order (to be mailed)


CLICK "SEND" AT THE BOTTOM OF THIS PAGE