usgreencardlottery.com

US Green Card Lottery Application

Please complete this application - To print a blank application form, click here

To have an application mailed to you, click here

Last Name

First Name

Middle Name

Date of Birth

DD

MM

YYYY

Male

Female

Birth City/Town

Birth Country

Mailing Address

Street Address

Address Line 2

City

State / Province

Postal / Zip Code

Country

Phone Number

Fax Number

E-Mail

Highest level of education

MINIMUM EDUCATION/WORK REQUIREMENTS: You must either have the equivalency of a U.S High School education OR have worked 2 years in a job that required at least 2 years of training .

Occupation / Work Experience

Occupation

Number of Years Experience

Marital Status

ADD PHOTO

If you can not upload a photo, you must send prints to complete the application process.

A SEPARATE COLOR PICTURE OF EVERY PERSON ON THIS APPLICATION IS REQUIRED. EACH PHOTO MUST COMPLY WITH ALL OF THESE RULES:
- FACE THE CAMERA, EYES OPEN AS SHOWN
- REMOVE GLASSES – NO GLASSES OF ANY KIND!
- NO HEAD COVERING, HATS OR SCARFS! (unless strictly required by your religion)
- PHOTO MUST BE IN COLOR ON A PLAIN WHITE OR LIGHT COLOR BACKGROUND

IF YOU CAN NOT UPLOAD YOUR PHOTOGRAPHS, SEND PRINTS
- On the back of each photograph type or print your:
- Full Name: (Underline last name),
- Date of Birth: DD-MM-YYYY, and
- Place of Birth: City, Province and Country as shown.

You must add your spouse (if married) and ALL children under the age of 21, including any adopted or step-children, even if they do not live with you or do not intend to immigrate.

Spouse

Children

Entry Options - Choose the best option for you

GUARANTEED ENTRY FOR ONE: NOT MARRIED - NO CHILDREN UNDER 21 YEARS OF AGE.

$50.00 FOR 1 YEAR

$90.00 FOR 2 YEARS

$125.00 FOR 3 YEARS

GUARANTEED ENTRY FOR FAMILY: MARRIED AND/OR HAVE CHILDREN UNDER 21

$75.00 FOR 1 YEAR

$125.00 FOR 2 YEARS

$165.00 FOR 3 YEARS

DOUBLE GUARANTEED ENTRY: RECOMMENDED FOR MARRIED COUPLES
Doubles the chances for a family to win, husband and wife each will be entered as a primary applicant

$125.00 FOR 1 YEAR

$190.00 FOR 2 YEARS

$275.00 FOR 3 YEARS

GUARANTEED ENTRY EVERY YEAR FOR THE LIFE OF THE PROGRAM
The surest way to win the lottery is to enter every year, under this option you will be GUARANTEED ENTRY EVERY YEAR for as long as the U.S. Government offers this program.

$250.00 FOR SINGLE PERSON

$350.00 FOR FAMILY

$500.00 FOR DOUBLE FAMILY

Payment

Method of Payment

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By completing and submitting this application you agree to engage the services of Mark Jacobsen, Attorney at Law, for the limited purpose of entering you in the United States Diversity Program. No other representation or legal service is implied or agreed to. No promises, inducements or guarantees as to the outcome of this service have been made. Please read the full Terms of Use before submitting this application

I have read and agree to the Terms of Use