DV Lottery Registration Form
Last Name (surname/family)
First Name, Middle Name
Birth Date (Day, Month, Year)
City/Town, District/County/Province, Country of Birth 
Applicant's Native Country (if Different from Country of Birth) 
Name, date, and place of birth of Spouse and Children (if any) 
Spouse's Name
Spouse's Date of Birth
Spouse Place of Birth
Child's Name
Child's Date of Birth
Child's Place of Birth
Child's Name
Child's Date of Birth
Child's Place of Birth
Mailing Information 
Street Address/Apt#/Suite#
City
State
Country
Zip/Postal Code
Sign Here (unsigned applications will not be processed) 
Signature