Application for Green Card

7. Enter applicant Photograph

11. E-mail Address, (NOTE: This e-mail address will be used to provide you with additional information if you are selected.) *

First Name *

14. Number of Children

1. Last / Family Name *

PAPERWORK REDUCTION ACT: Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: PRA_BurdenComments@state.gov.

CONFIDENTIALITY STATEMENT: The information asked for on this form is requested pursuant to Section 222 of the Immigration and Nationality Act. INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential and shall be used only for the formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of visa records may be made available to a court which certifies that the information contained in such records is needed in a case pending before the court.

c. Address Line 2 (optional)

5. Country where you were born *

9. Country Where You Live Today *

6. Country of Eligibility of the DV Program *

13. Legal separation is an arrangement when a couple remain married but live apart, following a court order. If you and your spouse are legally separated, your spouse will not be able to immigrate with you through the Diversity Visa program; however, you must include your spouse even if you plan to be divorced before you apply for the Diversity Visa. Failure to list your eligible spouse is grounds for disqualification. If your spouse is a U.S. citizen or Lawful Permanent Resident, do not list him/her in your entry.

g. Country *

10. Phone Number Optional *

b. Address Line 1 *

12. You must have a minimum of a high school diploma reflecting the completion of a full course of study (vocation schools or equivalency degrees are not acceptable) or be a skilled worker in an occupation that requires at least two years of training or experience to qualify (visit http://www.onetonline.org/ to see if your occupation qualifies) for a Diversity Visa.

Are you claiming eligibility based on the country where you were born? *

Yes

a. In Care Of (optional)

4. City where you were born *

DVL Application for Green Card

8. Mailing Address *

f. Postal Code/Zip Code *

3. Birth Date: mm/dd/yyyy *

Entries for the DV program must be submitted electronically

Middle Name *

14. Number of Children

Children include all biological children, legally adopted children, and stepchildren who are unmarried and under the age of 21 on the date you submit your entry. You must include all eligible children, even if they do not live with you or if they do not intend to apply for a Diversity Visa as your derivative. Failure to list all eligible children is grounds for disqualification. If your child is a U.S. citizen or Lawful Permanent Resident, do not list him/her in your entry.

Explanation about some Questions

11. (NOTE: This e-mail address will be used to provide you with additional information if you are selected.)

If not, you must enter the country from which you are claiming eligibility. *

d. City/Town *

2. Gender *

Male

Female

e. District/County/Province/State *

13. What is your current marital status?

Unmarried

Married and my spouse is NOT a U.S.citizen or U.S. Lawful Permanent Resident (LPR)

Married and my spouse IS a U.S.citizen or U.S. Lawful Permanent Resident (LPR)

Divorced

Widowed

Legally Separated