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USA Diversity Visa (DV) Program

Sorry, but this form is now closed, come back after November 10 to sign up for next year's lottery.

First name

As it appears on your passport

Middle Name (only if in passport)

Last name

As it appears on your passport

Gender

Birth Date

Month

Day

Year

City of birth

As it appears on your passport

Country of birth

As it appears on your passport

Country of eligibility for the DV program

Your country of eligibility will normally be the same as your country of birth. Your country of eligibility is not related to where you live or your nationality if it is different from your country of birth.

Photograph (.jpg)

Mailing Address - Street and number

Mailing Address - City/Town

Zip/Postal Code

Country where you live today

Phone number

Email address

Highest level of education you have achieved, as of today:

Current marital status

You must list your spouse even if you currently are separated from them unless you are legally separated.

If your spouse is a U.S. citizen or Lawful Permanent Resident, do not list them in your entry.

IF MARRIED: Name of spouse

IF MARRIED: Date of birth of spouse

IF MARRIED: Gender of spouse

IF MARRIED: City of birth of spouse

IF MARRIED: Country of birth of spouse

IF MARRIED: Photo of spouse

Number of children

If you have children, please fill in the information below for each child.

If you have more than 4 children, please contact us to intake their information.

IF CHILDREN: Name of child 1

IF CHILDREN: Date of birth of child 1

IF CHILDREN: Gender of child 1

IF CHILDREN: City of birth of child 1

IF CHILDREN: Country of birth of child 1

IF CHILDREN: Photo of child 1

IF CHILDREN: Name of child 2

IF CHILDREN: Date of birth of child 2

IF CHILDREN: Gender of child 2

IF CHILDREN: City of birth of child 2

IF CHILDREN: Country of birth of child 2

IF CHILDREN: Photo of child 2

IF CHILDREN: Name of child 3

IF CHILDREN: Date of birth of child 3

IF CHILDREN: Gender of child 3

IF CHILDREN: City of birth of child 3

IF CHILDREN: Country of birth of child 3

IF CHILDREN: Photo of child 3

IF CHILDREN: Name of child 4

IF CHILDREN: Date of birth of child 4

IF CHILDREN: Gender of child 4

IF CHILDREN: City of birth of child 4

IF CHILDREN: Country of birth of child 4

IF CHILDREN: Photo of child 4

Total Price

€49.9

Please review all your information before submitting. You will be automatically directed to the payment page when clicking "submit".