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In
year 2021 lottery DV-2023 (October - November, 2021)
1. Family
name, first name, middle name (as shown
on your passport):
. . .
. . . . . . . .
. . . . , . . .
. . . . . . . .
. . . . .
, . . .
. . . . . . . .
. . .
Last Name
First Name
Middle Name
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2. Date of birth: . . .
. . . . . . . .
. . . . . .
. . . . . . . .
. . . . . .
. . . . . . . .
Day, Month
(write day and month), year |
3. Place where you were born: . . . . . . .
. . . . . . . .
. . . . . . . . .
. . . . . . . .
City / Country |
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4. Gender:
check off box; mail female |
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5. Country of birth: check
off box; Poland
write
country . . . . . . . . . . . . . . . .
. . . . . |
6. Country where your spouse was born if deferent than your birth
country:
. . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . |
7. Valid Passport: Number#, Date (m/d/y), Country/Authority of Issuance:
. . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . |
8. Country where of your parents were born if deferent than your
birth country:
. . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . |
9. Highest level of education you have achieved as of today:
check off box;
primary school, some high school no degree, high school with
degree,
vocational school, some university
courses,
university
degree,
some graduate level courses, master degree, some doctoral courses,
doctorate. |
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10. Country where you live today: . . . . . .
. . . . . . . .
. . . . . . . . .
. . . . . |
| 11.
Current Martial Status: check off box; married single widow divorced |
| 12.
Spouse's information
(wife/husband): |
If you are married you need to submit these information:
Spouse's last name, first name, middle name:
. . .
. . . . . . . .
. . . . .
, . . .
. . . . . . . .
. . . . .
, . . .
. . . . . . . .
. . .
Last Name
First Name
Middle Name
Spouse's
Date of birth: . . .
. . . . . . . .
. . . . . .
. . . . . . . .
. . . . . .
. . . . . . .
Day, Month
(write day and month), year
Spouse's Place of birth:
. .
. . . . . . . .
. . . . . . . .
. . . . . . . .
. . . . . . . . . . . . .
.
City / Country
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| 13. Do
you have living unmarried children under 21 year old: check
off box;
Yes No |
| 14.
List of living,
unmarried children under 21 year old if you have: |
Child Name: . . . .
. . . . . . . . . . . . . . . . . . . , . . . . . .
. . . . , .
. . . . . . . .
.
Last
Name
First Name Middle Name
Date of
birth: . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . . . . .
Day, Month
(write day and month), year
Place of
birth: . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . .
City / Country
Child Name:
. . . . . . . . . . . . . . . . . . . . . . . ,
. . . . . .
. . . . , .
. . . . . . . .
. . .
Last
Name
First Name
Middle Name
Date of birth: .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . .
Day, Month
(write day and month), year
Place of birth: . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . .
City / Country
*if you have more children, please add in the back or on additional
sheet.
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15. Full
correspondence address:
street
city/town
district/province/state
postal code/zip code
country |
________________________________
________________________________
________________________________
________________________________
________________________________
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14a.
Photo (s)
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Picture requirements: Here
Write
name on the back of the picture.
Picture can be return for additional payments
$5.00. |
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16. Phone number (optional):
. . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
17. Address E-mail (optional):
. . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . |
Date:
____/________________/________
(Day,
Month, Year) |
Office
Use:
Received date:
Filled out date:
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