Order Form for Green Card Lottery
First Name  
Last Name 
Middle Name
Date of Birth (Day/Month/Year)
Place of Birth:
Town
Province
Country
Applicant's Native Country
Education College Degree
High School or equivalent
Are you Married? Yes   No
How many children do you have?
Age of children
(Please fax or e-mail this form to us and we will contact you to complete the official form .)
Your First Name
Last Name
(If you are applying for someone else)
Address
Address 2
City
State
Zip Code
Country
Telephone
Fax
E-mail address
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