PLEASE
PRINT OUT THIS PAGE
U.S. DIVERSITY VISA LOTTERY PROGRAM
DV-2002
LAST NAME ______________________________
FIRST NAME _______________________ MIDDLE NAME _____________________
DATE OF BIRTH
__________________________________________
DAY MONTH YEAR
PLACE OF BIRTH
____________________________________________________________________________
CITY/TOWN DISTRICT/PROVINCE COUNTRY
APPLICANTS NATIVE COUNTRY IF DIFFERENT FROM COUNTRY OF BIRTH
______________________________________________________________
SPOUSE FULL NAME(IF ANY)
___________________________________________________________________________
LAST (surname/family) MIDDLE FIRST
DATE OF BIRTH
____________________________________________
DAY MONTH YEAR
PLACE OF BIRTH
____________________________________________________________________________
CITY/TOWN DISTRICT/PROVINCE COUNTRY
UNMARRIED CHILDREN UNDER 21:
_________________________________________________________________________________________
NAME (CHILD 1) BIRTHDATE(DAY-MONTH-YEAR) PLACE OF BIRTH
_________________________________________________________________________________________
NAME (CHILD 2) BIRTHDATE(DAY-MONTH-YEAR) PLACE OF BIRTH
_________________________________________________________________________________________
NAME (CHILD 3) BIRTHDATE(DAY-MONTH-YEAR) PLACE OF BIRTH
APPLICANTS MAILING ADDRESS ____________________________________________________________
_________________________________________________________________________________________
APPLICANT'S SIGNATURE ___________________________________
PHONE ___________________________________
E-MAIL ___________________________________
Please complete application, Sign it and attach 37mm x 37mm photo with your name on the back.
Fees: $40.00 for single application $70.00 for family 2 applications.
Payment forms:
U.S.or Canadian Money Order, U.S.or Canadian Cashiers
Check, Check Drawn on Canadian or U.S. Bank, International Money Order
International Bank Draft, International Postal Order,
Foreign Postal Money Order.
Make Checks/Money Order payable to
:
Immigration nternational LTD
Mail To :
Immigration Interntional Lottery center
208-233 Duckworth st
St.John's
Newfondland, A1C5R6
CANADA
