Please follow these instructions carefully in order to complete your application.
1. APPLICANT'S FULL NAME:
Surname (last name/family name), First Name and Middle Name.
EXAMPLE: Smith, John Patrick
2. GENDER: Male or female
3. DATE OF BIRTH:
Day, Month, Year
EXAMPLE: 15 November 1971
4. PLACE OF BIRTH:
Place: City/Town, District/County/Province, Country
EXAMPLE: Naas, Kildare, Ireland
5. NATIVE COUNTRY (IF DIFFERENT FROM COUNTRY OF BIRTH):
If you are claiming nativity in a country other than your place of birth, indicate that country. This country could be either your spouse's country
of birth or your mother/father's country of birth. Please indicate if you are claiming the nativity of a spouse or the nativity of a parent.
6. MARITAL STATUS
7. NUMBER OF UNMARRIED CHILDREN UNDER 21 YEARS OF AGE
8. NAME, DATE AND PLACE OF BIRTH OF SPOUSE AND CHILDREN:
Entries must include the name, date and place of birth of your spouse and all natural children (as well as all legally-adopted and stepchildren)
who are unmarried and under the age of 21. You do not need to include those children who are already U.S. citizens or Legal Permanent
Residents. The above mentioned must be included even if you are no longer legally married to the child's parent, and even if the spouse or
child does not currently reside with you and/or will not immigrate with you. Note that married children and children 21 years or older will not
qualify for the diversity visa.
9. FULL MAILING ADDRESS:
This must be clear and complete, because any future mailings will be sent there.
10 & 11. TELEPHONE NUMBER & EMAIL ADDRESS
A telephone number and e-mail address are optional, but useful.
- Include a recent photograph either in colour or black and white.
- If you are including your spouse or children in your application, please submit a separate photograph for each family member.
Photographs must conform to the following specifications:
Photographs must be taken with a new digital image or a digital scanner should be used to scan a submitt