Complete, Print, and Mail your Signed Application to the address below with:1) Photo & 2) Processing fee.        

U.S. DIVERSITY VISA LOTTERY APPLICATION


Applicant's Last Name


First              Name


Middle


Date of Birth (Day/Month/Year)


Place of Birth (City/Town, District/Province, Country)


Applicant's Native Country, ONLY if different from country of birth

Name, date and place of birth of the Applicant's Spouse and Children (IF ANY)


Spouse Last Name


First              Name


Middle


Date              of Birth (Day/Month/Year)


Place of Birth (City/Town, District/Province, Country)


Child 1 Last Name


First              Name


Middle


Date of Birth (Day/Month/Year)


Place of Birth (City/Town, District/Province, Country)


Child 2 Last Name


First              Name


Middle


Date of Birth (Day/Month/year)


Place of Birth (City/Town, District/Province, Country)


Child 3 Last Name


First              Name


Middle

 

 


Date of Birth (Day/Month/year)

 

 


Place of Birth (City/Town, District/Province, Country)

If you have more than 3 children list them on the back of the application

Complete Mailing Address:

Telephone:

Signature:

 
_____________________________________

 

                                         Order  Information

Order
Placed
By

 

Your Name:

Your Email:

Your Address:

City:


State: Zip:

Country:

Your Telephone:

Your Fax:

Payment

 

PAYMENT -- Make payment to:  Dobbs & Neidle, PC

Our processing fee is only $25 (US) for one application, and only $45 for two applications (husband and wife).

Payment by

Account Number

Expiration

mm/yy

Cardholder Name

 

 

 

 

 

INSTRUCTIONS:

Step One
 Complete, Print (Press File-Print), and Mail your signed application to address below with: Photo and Processing Fee.  If you have additional children, please list on back.

If you are married, you and your spouse may each enter separate applications and double your chances of winning. Both applications must be completely filled out and signed by the applicant and include the other spouse and all unmarried children under the age of 21.

Step Two
Have a facial portrait.  Size of the photograph must be 1 1/2 inch x 1 1/2 inch (37 mm x  37mm). Print your full name on reverse side of photograph. You must submit two photographs. Do not attach your photograph to your application. We will do this for you before submitting the application to the lottery.            

Step Three
 Mail application form, photographs and payment to:

Dobbs & Neidle, PC
17290 Farmington Road
Livonia, MI  48152
USA

Individual application $ 25.00 US
Dual application $ 45.00 US