FOR DV LOTTERY, CONTACT: 654291720
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)
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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:
CONTACT: 654291720
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