FORM TO FILL FOR DV LOTTERY

FULL NAMES AS ON BIRTH CERTTIFICATE:

LAST/FAMILY NAME:

FIRST NAME:

MIDDLE NAME:

DATE OF BIRTH:

MONTH:

DAY:

YEAR:

PLACE OF BIRTH

Enter Birth City Only (Do not enter District/County/Province/State)

*Country Where You Were Born*

E-Mail Address: (e.g. johndoe@example.com)

Phone Number:

What is the highest level of education you have achieved, as of today?

What is your current marital status?

Number of Children:

CURRENT CITY/TOWN:

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