SAMPLE ENTRY FORM

There is no specific format for the DV entry form.
The following sample form is provided to help
facilitate the entry process, but other formats may be used.
Failure to provide all of the required information will disqualify
the applicant.

1. FULL  NAME:______________________________	________________________
		  LAST (surname/family)	                FIRST

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           Place of birth 
                              (day,month,year) 

_______________________      ____________________    _____________________ 
          Name                 Date of birth           Place of birth 
                              (day,month,year) 

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.