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Home > DV-2002 > Entry Form

Green Card Lottery Entry

LAST NAME (Family/Surname)
First Name
Middle Name
DATE OF BIRTH  Day         Month          Year
PLACE OF BIRTH
City/Town
District/County/ Province
Country
NATIVE COUNTRY IF DIFFERENT FROM COUNTRY OF BIRTH
FULL NAME, DATE , CITY & COUNTRY OF BIRTH OF SPOUSE AND CHILDREN:
Spouse
Last(Family) Name First Name Middle Name
DATE OF BIRTH  Day         Month          Year
PLACE OF BIRTH
City/Town
District/County/ Province
Country
Child#1
Last(Family) Name First Name Middle Name
DATE OF BIRTH  Day         Month          Year
PLACE OF BIRTH
City/Town
District/County/ Province
Country
Child#2
Last(Family) Name First Name Middle Name
DATE OF BIRTH  Day         Month          Year
PLACE OF BIRTH
City/Town
District/County/ Province
Country
Child#3
Last(Family) Name First Name Middle Name
DATE OF BIRTH  Day         Month          Year
PLACE OF BIRTH
City/Town
District/County/ Province
Country
Child#4
Last(Family) Name First Name Middle Name
DATE OF BIRTH  Day         Month          Year
PLACE OF BIRTH
City/Town
District/County/ Province
Country
FULL MAILING ADDRESS
Name
Address 
City
District/State/Province
Postal Code
Country
PHONE (Optional)
SIGNATURE
 
   
EMAIL ADDRESS (Optional)  
 
IMPORTANT: Your signature must be on page 1 of your entry form. Your email address may be on a second page if it does not fit on page 1.

1. Print this Entry Form.
2. If your Entry Form information is correct, click on the "Submit Information" button below.

 

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