LAST NAME (Family Name/Surname) First Name Middle Name DATE OF BIRTH Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 PLACE OF BIRTH City/Town (Required) District/County/ Province Country (Required) Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Cape Verde Central African Republic Chad Chile Comoros Congo Congo, Democratic Republic of the Costa Rica Cote D'Iviore (Ivory Coast) Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica East Timor Egypt Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France France Reunion Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guinea Guinea-Bissau Guyana Honduras Hong Kong Special Administrative Region Hungary Iceland Indonesia Iran Iraq Ireland Israel Italy Japan Jordan Kazakstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau S.A.R. Macedonia, the Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Micronesia, Federated States of Moldova Monaco Mongolia Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles Netherlands Aruba New Zealand Nicaragua Niger Nigeria North Korea Northern Ireland Norway Oman Palau Panama Papua New Guinea Paraguay Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates Uruguay Uzbekistan Vanuatu Vatican City Venezuela Yemen Yugoslavia, Federal Republic of Zambia Zimbabwe NATIVE COUNTRY IF DIFFERENT FROM COUNTRY OF BIRTH COUNTRY WHERE YOU LIVE TODAY (Required) Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad China Chile Colombia Comoros Congo Congo, Democratic Republic of the Costa Rica Cote D'iviore (Ivory Coast) Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea England Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Special Administrative Region Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau S.A.R. Macedonia, the Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles Netherlands Aruba New Zealand Nicaragua Niger Nigeria North Korea Northern Ireland Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and Grenadines San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom USA Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Western Samoa Yemen Yugoslavia, Federal Republic of Zambia Zimbabwe HIGHEST LEVEL OF EDUCATION YOU HAVE ACHIEVED, as of today (Required) Primary School Only High School, No Degree High School Degree Vocational School Some University Courses University Degree Some Graduate Level Courses Master Degree Some Doctorate Level Courses Doctorate Degree PLEASE NOTE: If you selected (1) Primary school only or (2) High school, no degree or (4) Vocational school, from the above list you must then meet the work experience requirements in order to enter the Lottery. Information about work experience requirements and a list of acceptable jobs is available on our web page www.americangreencard.com/howenter.htm . Only you can decide if you meet the work experience requirements. We cannot advise you about that. MARITAL STATUS (Required) Unmarried Married Divorced Widowed Legally Separated NUMBER OF CHILDREN (Include all natural children, as well as all legally- adopted children and stepchildren, who are unmarried and under the age of 21) (Required) 0 1 2 3 4 5 6 7 8 9 10 FULL NAME AND DATE of BIRTH AND CITY & COUNTRY of BIRTH OF SPOUSE AND EACH CHILD AND SEX of EACH: Spouse Child #1 Child #2 Child #3 Child #4 Child #5 Child #6 Child #7 Child #8 FULL MAILING ADDRESS Name (Required) Address Line 1 (Required) Address Line 2 Address Line 3 City (Required) District/State/Province (Required) Postal Code Country (Required) Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad China Chile Colombia Comoros Congo Congo, Democratic Republic of the Costa Rica Cote D'iviore (Ivory Coast) Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea England Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Special Administrative Region Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau S.A.R. Macedonia, the Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles Netherlands Aruba New Zealand Nicaragua Niger Nigeria North Korea Northern Ireland Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and Grenadines San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom USA Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Western Samoa Yemen Yugoslavia, Federal Republic of Zambia Zimbabwe PHONE (Optional) EMAIL ADDRESS Step #1 - When all of your entry data above is correct, click on the "Submit Information" button below. Step #2 - Email us the required digital photos after June 3, 2009. Complete instructions on how to prepare your digital photos and how to email them to us are on our web page www.americangreencard.com/howenter.htm. Step #3 - Send us your service fee for Lottery DV-2011. Complete instructions on how to send your service fee are on our web page www.americangreencard.com/howenter.htm .We will review your digital photos after receiving our service fee.
NATIVE COUNTRY IF DIFFERENT FROM COUNTRY OF BIRTH
Step #1 - When all of your entry data above is correct, click on the "Submit Information" button below. Step #2 - Email us the required digital photos after June 3, 2009. Complete instructions on how to prepare your digital photos and how to email them to us are on our web page www.americangreencard.com/howenter.htm. Step #3 - Send us your service fee for Lottery DV-2011. Complete instructions on how to send your service fee are on our web page www.americangreencard.com/howenter.htm .We will review your digital photos after receiving our service fee.
OUR SERVICE FEE: $60 for each digital photo we correct to meet the Green Card Lottery requirements. return to top return to home page [ Frequently Asked Questions ] [ Eligible Countries ] [ Instructions on How to Enter ] [ Our Services and Fees ] [ Entry Form ] [ Contact Us ] [ Home Page ]