DV Lottery Registration

Use only Latin letters

1. Name

1a. Last Name

1b. First Name

1c. Middle Name

No middle name

2. Birth Date

3. Gender

Male

Female

4. City Where You Were Born 5. Country Where You Were Born 6. Country of Eligibility for the DV Program

Yes

Active only if you selected "No" above 7. Entrant Photograph

8. Mailing Address

9. Country Where You Live Today 10. Phone Number (optional) 11. E-mail Address 12. What is the highest level of education you have achieved? 13. What is your current marital status? 14. Number of Children

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