DV 2003 FORM
1. FULL NAME: ___________________________
______________________ ___________________
LAST (surname/family)
FIRST MIDDLE
2. DATE OF BIRTH: _____________________________
Day, Month, Year
PLACE OF BIRTH:
_____________________________________________________________
City/Town,
District/County/Province, Country
3. APPLICANT'S NATIVE COUNTRY IF DIFFERENT FROM COUNTY OF BIRTH:
__________________________________________________________________
____________
4. NAME, DATE AND PLACE OF BIRTH OF THE APPLICANT'S SPOUSE AND CHILDREN
(IF ANY)
___________________________ _________________________
_______________________
Name
Date of birth(day,month,year) Place of birth
___________________________ _________________________
_______________________
Name
Date of birth(day,month,year) Place of birth
___________________________ _________________________
_______________________
Name
Date of birth(day,month,year) Place of birth
___________________________ _________________________
_______________________
Name
Date of birth(day,month,year) Place of birth
___________________________ _________________________
_______________________
Name
Date of birth(day,month,year) Place of birth
Attach information on
additional child(ren) as necessary.
5. FULL MAILING ADDRESS:
_________________________________________________
________________
_________________________________
________________
_________________________________
________________
_________________________________
________________
_________________________________
6. PHOTOGRAPH: (Attach a recent, preferably less than 6 months old,
photograph of the applicant,
1.5 inches (37 mm) square in
size, with the applicant's name printed on the back.
The photograph (not a photocopy)
should be attached to the entry with clear
tape--do NOT use staples or
paperclips, which can jam the mail processing
equipment.)
7. SIGNATURE: _____________________________________________________
Failure to personally sign the
entry will disqualify the applicant.
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