DV REGISTRATION FORM
Instructions: Fax us this form to "Immigration & Visa Center, Inc." (954) 727- 3981 or scan this document and send it as an
attachment usimmigrationnet@yahoo.com Your passport photo can sent online or via mail: IVC., 10186 NW 47th Street, Sunrise, Fl 33351.
1. FULL NAME: -------------------------------------- ------------------------------------ -----------------------------------------
LAST NAME FIRST NAME MIDDLE NAME)
2. DATE OF BIRTH:
------------------------------------------------(Month/Day/ Year)
3. PLACE OF BIRTH: ----------------------------------------------------------------
APPLICANTīS NATIVE COUNTRY
(City, Town, District/County/ Providenze, Country of Birth
4. APPLICANTīS NATIVE COUNTRY IF DIFFERENT FROM COUNTRY OF BIRTH:
----------------------------------------------------------------------------------------------------------------
5. NAME, DATE & PLACE OF BIRTH
OF THE APPLICANTīS SPOUSE & CHILDREN(IF ANY)
---------------------------------- ------------------------ -------------------------- -------------------
NAME OF SPOUSE DATE OF BIRTH PLACE OF BIRTH (Month/Day/Year)
---------------------------------- ------------------------- --------------------------- -------------------
CHILDīS NAME DATE OF BIRTH PLACE OF BIRTH (Month/Day/Year)
---------------------------------- --------------------------- --------------------------- -------------------
CHILDīS NAME DATE OF BIRTH PLACE OF BIRTH (Month/Day/Year)
6. FULL MAILING ADDRESS:
------------------------------------------------------------------------------------------------------------------------
STREET ADDRESS/ APT #
----------------------- -------------- ----------------- ------------------------- ----------------------------
CITY STATE COUNTRY ZIP/POSTAL CODE HOME PHONE
7. PHOTOGRAPH:
Attach a recent (less than 6 months old) 1.5 inches (37 mm) square
photograph with the applicantīs name printed on the back
by using clear tape.
8.- SIGNATURE of the APPLICANT:
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