DV-2004 LOTTERY REGISTRATION

1.   FULL NAME: ___________________________       ______________________________ 
                              Last (surname/family)--Underlined                                   First

 2.      DATE OF BIRTH: __________________________
                                                Day, Month, Year 

      PLACE OF BIRTH: __________________________________________________
                                                    City/Town, District/County/Province, Country 

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

4.      NAME, DATE AND PLACE OF BIRTH OF THE APPLICANT'S SPOUSE AND CHILDREN (IF ANY): 
_______________________    _______________________     _______________________
                   Name                       Date of birth (day, month, year)               Place of birth        

        ______________________     _______________________     _______________________
                         Name                       Date of birth (day, month, year)               Place of birth  

        ______________________     ________________________    _______________________
                         Name                       Date of birth (day, month, year)               Place of birth

Attach information on additional child(ren) as necessary. 

5.       FULL MAILING ADDRESS: ________________________________________________
                                                  ________________________________________________
                                                  ________________________________________________

    Telephone No. (Optional, but helpful): _______________________

6.       PHOTOGRAPH: (Name and date of birth on back of photo):  

7.    SIGNATURE:______________________________________
                                                  (Required)
                               

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