Diversity Immigrant Visa Program Entry Form


1. Applicant's Full Name: ____________________ ____________________ ____________________
                   (Surname/Family Name)                     (First)         (Middle)


2. Applicant's Date of Birth: ____________________________________________________________
(Day) (Month) (Year)


    Place of Birth: ____________________________________________________________________
(City/Town) (District/County/Province) (Country)


3. Applicant's Native Country (if different):___________________________________________________


4. Name, Date, and Place of Birth of Applican'ts Spouse and Children (if any):

Spouse:
____________________   ____________________   ____________________
  (Name) (Date of Birth) (Place of Birth)

Child:
____________________   ____________________   ____________________
  (Name) (Date of Birth) (Place of Birth)

Child:
____________________   ____________________   ____________________
  (Name) (Date of Birth) (Place of Birth)


5. Full Mailing Address:_________________________________________________________________
 
                    __________________________________________________________
 
                    __________________________________________________________
 
                    __________________________________________________________


TELEPHONE NO:__________________________________________________________________


6. Attach a recent photograph, 2 X 2 inches (50mm X 50mm) with the Applicant's name printed on the back. Use clear tape to attach the photgraph, not staples or paperclips.


7. SIGNATURE: ___________________________________________________________________


For more information about how Deborah Chew & Associates
can help you with your legal needs,
Please call Deborah at (858) 638 - 9008
or send e-mail to dchew@deborahchew.com




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