DV-2011 U.S. DIVERSITY VISA LOTTERY APPLICATION
http://gclottery.stockholmian.com
Read the seperate
instructions BEFORE filling or
posting this form |
Applicant's Last Name |
First Name |
Date of Birth (Day/Month/Year) |
Place of Birth (City / Province / Country) |
|
Unmarried Married
Divorced Widowed
Legally Seperated |
|
|
| Name,
date and place of birth of the Applicant's Spouse |
Spouse Last Name |
First Name |
Date of Birth (Day/Month/Year) |
Place of Birth (City/Town, Country) |
| Name,
date and place of birth of the applicant's unmarried children under 21 years of
age |
Child 1 Last Name |
First Name |
Date of Birth (Day/Month/Year) |
Place of Birth (City/Town, Country) |
Child 2 Last Name |
First Name |
Date of Birth (Day/Month/year) |
Place of Birth (City/Town, Country) |
Child 3 Last Name |
First Name |
Date of Birth (Day/Month/year) |
Place of Birth (City/Town, Country) |
| If
you have more than 3 children list them on the back of the application |
Complete
Mailing Address.
NOTE: This is the address that will be used to notify you if you are selected.
Do not forget your postal code, for Iran 10 digits.
Phone:
Email:
Mobile: |
PLEASE
NOTE THAT WE WILL NOT REFUND PAYMENTS AFTER YOUR LOTTERY APPLICATION HAS BEEN
SENT TO THE CONSULAR CENTER. I declair that I know the contents of this
application that I am signing, including the attached documents and
supplements. I sign this form personaly.
Signature:______________________________
Check List:
Signed Entry
Form
Photograph(s)
Correct
Payment
Entries received
without signature, photograph and correct payment will not be processed.DO NOT
USE THIS FORM AFTER DECEMBER 1 2009. Get the updated form from:
http://gclottery.stockholmian.com
|