Green Card Lottery Application
Applicant Information		*Please type in Alphabet
Full Name	First Name	Middle Nmae	Last Name
Birth Date	--Month--JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember   --Day--12345678910111213141516171819202122232425262728293031 ,  --Year--1940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012
Gender	Male   Female
Birth Place	City/Town	States/Province
	Country --------------------Select Country--------------------United StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArubaArubaAshmore and Cartier IslandsAustraliaAustriaAzerbaijanBahamasBahrainBaker IslandBangladeshBarbadosBassas da IndiaBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChina-TaiwanChristmas IslandClipperton IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCoral Sea IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropa IslandFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern and Antarctic LandsGabonGambiaGazaGeorgiaGermanyGhanaGibraltarGlorioso IslandsGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong Special Administrative RegionHowland IslandHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJan MayenJapanJarvis IslandJerseyJohnston AtollJordanJuan de Nova IslandKazakhstanKenyaKingman ReefKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau Special Administrative RegionMacedonia, The Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMan, Isle ofMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMidway IslandsMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueNamibiaNauruNavassa IslandNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern IrelandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian AuthorityPalmyra AtollPanamaPapua New GuineaParacel IslandsParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint Kitts and NevisSaint LuciaSaint MartinSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSpratly IslandsSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTromelin IslandTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, USWake IslandWallis and FutunaWest BankWestern SaharaYemenZambiaZimbabwe
In what Country do you live today?	Country --------------------Select Country--------------------United StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArubaArubaAshmore and Cartier IslandsAustraliaAustriaAzerbaijanBahamasBahrainBaker IslandBangladeshBarbadosBassas da IndiaBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChina-TaiwanChristmas IslandClipperton IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCoral Sea IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropa IslandFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern and Antarctic LandsGabonGambiaGazaGeorgiaGermanyGhanaGibraltarGlorioso IslandsGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong Special Administrative RegionHowland IslandHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJan MayenJapanJarvis IslandJerseyJohnston AtollJordanJuan de Nova IslandKazakhstanKenyaKingman ReefKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau Special Administrative RegionMacedonia, The Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMan, Isle ofMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMidway IslandsMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueNamibiaNauruNavassa IslandNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern IrelandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian AuthorityPalmyra AtollPanamaPapua New GuineaParacel IslandsParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint Kitts and NevisSaint LuciaSaint MartinSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSpratly IslandsSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTromelin IslandTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, USWake IslandWallis and FutunaWest BankWestern SaharaYemenZambiaZimbabwe
Education Level
What is the Heighest Level you have achieved?	-Primary SchoolHigh School with No DegreeHigh School with some DegreeVocational SchoolSome University CoursesAssociate DegreeUniversity Degree/Bachelor's DegreeSome Graduate Level CoursesMaster DegreeSome Doctorate Level CoursesDoctorate Degree
Contact Information
Mailing Address	Address
	City/Town	State/Province	Postal Code
	Country --------------------Select Country--------------------United StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArubaArubaAshmore and Cartier IslandsAustraliaAustriaAzerbaijanBahamasBahrainBaker IslandBangladeshBarbadosBassas da IndiaBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChina-TaiwanChristmas IslandClipperton IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCoral Sea IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropa IslandFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern and Antarctic LandsGabonGambiaGazaGeorgiaGermanyGhanaGibraltarGlorioso IslandsGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong Special Administrative RegionHowland IslandHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJan MayenJarvis IslandJerseyJohnston AtollJordanJuan de Nova IslandKazakhstanKenyaKingman ReefKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau Special Administrative RegionMacedonia, The Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMan, Isle ofMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMidway IslandsMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueNamibiaNauruNavassa IslandNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern IrelandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian AuthorityPalmyra AtollPanamaPapua New GuineaParacel IslandsParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint Kitts and NevisSaint LuciaSaint MartinSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSpratly IslandsSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTromelin IslandTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, USWake IslandWallis and FutunaWest BankWestern SaharaYemenZambiaZimbabwe
Phone Number
E-mail	(Confirm)
Marital Status and Number of Children
Marital Status	---------Select---------UnmarriedMarriedDivorcedWidowedLegally Separated
Number of Children	---Select---0123456789101112131415
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