Immigration - Green Card Lottery


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Your First Name:

Your Middle Name: (if applicable)

Your Last Name:

Other Names Used (including maiden name):

Sex: MaleFemale

What is your Complete Current Street Mailing Address?

Address:

City:

State/Province:

Country:

Postal/Country Code:

Do you your home?

Home Phone:

Work Phone

Fax Number:

Email Address:

Your Place of Birth:

Birth Country:

City:

State/Province:

Your Birthdate: Month: Day: Year:

Are you married? YesNo

Number of Children

Your Username:

Your Password:

National Visa Registry
A Non-Governmental Agency

Telephone: (818) 784-4618
Fax: (818) 905-1937

Mail Applications to:

Application Processing Center
PMB 725
16161 Ventura Boulevard
Encino, CA 91436-2523

Last Modified 09/14/2004