U.S. Diversity Immigrant Visa Lottery Application

PART 1 - Main Applicant:
Applicant’s Full Name:

Last / Family Name
         First & Middle
Applicant’s Date of Birth: 
Day
Month
Year 		Gender: 
Place of Birth: 
                                       City / Town
         Country 		  
Applicant is charging nativity to : 

   (Only if Different from Country of Birth)
     (Mark a box)    Parent's country of birth   Spouse's country of birth 

Applicant's Full Mailing Address:
            

Street Address

City / Town
 
State / Province  & Post Code

Country
E-mail. 
Tel No.   (optional)

PROCESSING 
FEES:  		Our processing fee for ONE application is only US$40 - regardless of how many members are in the family. A husband and wife may double the Chances Of Winning  by sending TWO separate applications. The "husband and wife" entries will be processed for US$60. Please send both applications in one envelope.
We accept:   - International Money Order,
  - International Bank Draft or
  - US dollars Cash - send it as registered or insured
    Please make payment in US dollars made out to: FAIR HILLS PTY. LTD.
Mail this Application, Photo(s) and Payment to our
Photo Processing Center: 		  Fair Hills
  PO Box 48736
  E1 7WT
  UK



U.S. Diversity Immigrant Visa Lottery Application

PART 2 - Spouse:
Sposue’s Full Name:

Last / Family Name
         First & Middle
Date of Birth: 
Day
Month
Year 		Gender: 
Place of Birth: 
                                       City / Town
         Country