GREENCARD - US - IMMIGRATION LOTTERY

2. APPLICANT'S DATE OF BIRTH:

Day:___________ Month: _______________ Year: ____________

3. NAME, DATE AND PLACE OF BIRTH OF APPLICANT'S SPOUSE AND CHILDREN, IF ANY.

SPOUSE'S NAME: _________________________

DATE OF BIRTH:__________________________

PLACE OF BIRTH:_________________________

CHILD'S NAME: __________________________

DATE OF BIRTH:__________________________

PLACE OF BIRTH:_________________________

4. APPLICANT'S MAILING ADDRESS:

____________________________________________

PHONES:

_____________________________

4. APPLICANT'S NATIVE COUNTRY IF DIFFERENT FROM COUNTRY OF BIRTH:

____________________________________________

5. APPLICANT'S 2 inch x 2 inch PHOTOGRAPH IS ENCLOSED:

FOTO 2 x 2 inches
(50 x 50 mm)
Your full name and signature must
be on the back of the photograph.

7. DATE: __________________ APPLICANT'S SIGNATURE: _____________________________