VERY CAREFULLY review this EXAMPLE to see how you should complete your own application. All details are VERY IMPORTANT. Write YOUR information on the BLANK application form and sign it. Attach photograph(s) with tape (DO NOT staple).

Send your application form + your photograph + payment to: .............................

If you are married, your spouse can complete another application, following the same steps (1. through 4. above). If both you and your spouse send your applications, your chance to become permanent residents of the U.S.A. will be twice as high.

1. FULL NAME with last name (also known as surname or family name) underlined:

   Lopez, Juan Antonio
   --------

2. DATE AND PLACE OF BIRTH (number for day, word for month, number for year; city or town or village, district or county or province, country):

   15 November 1961

   Munich, Bavaria, Germany

As "country," use the name of your country of birth as it is currently in use (for example, Slovenia rather than Yugoslavia; Kazakhstan rather than Soviet Union).

3. THE APPLICANT'S NATIVE COUNTRY IF DIFFERENT FROM COUNTRY OF BIRTH:

If you were born in an "eligible country," leave this space blank.

If you were NOT born in an "eligible country," but your spouse WAS born in an "eligible country," write the name of the country where your spouse was born.

Or, if YOU were NOT born in an "eligible country," but NEITHER of your parents was born in the country in which you were born, or resided in that country at the time of your birth, and at least one of your parents was born in an "eligible country," write the name of such an "eligible country" in which one of your parents was born.

4. NAME, DATE AND PLACE OF BIRTH OF THE APPLICANT'S SPOUSE AND ALL NATURAL CHILDREN, AS WELL AS ALL LEGALLY-ADOPTED AND STEPCHILDREN, WHO ARE UNMARRIED AND UNDER THE AGE OF 21 YEARS, EVEN IF YOU ARE NO LONGER LEGALLY MARRIED TO THE CHILD’S PARENT, AND EVEN IF THE CHILD DOES NOT CURRENTLY RESIDE WITH YOU AND/OR WILL NOT IMMIGRATE WITH YOU (Note that married children and children 21 years or older will not qualify for the Diversity Visa. Failure to list all children will result in your disqualification for the visa.):

   Lopez, Paola Carla; 27 February 1965; Munich, Bavaria, Germany

Write full name, date of birth (number for day, word for month, number for year) and place of birth (city or town or village, district or county or province, country) of your spouse and all unmarried children under 21.

5. FULL MAILING ADDRESS:

   Hauptbahnstrasse 37 A, 63528 Munich, Bavaria, Germany

6. PHOTOGRAPH(S):

Tape (DO NOT staple) one recent (preferably less than 6 months old) photograph of the applicant, the applicant’s spouse, and all children. Print the name and date of birth of each family member on the back of each photograph. Failure to submit required photos for all family members will result in disqualification. The photographs must be 50 mm x 50 mm (2 inches x 2 inches) in size.

7. SIGNATURE: _______________________________________