| Electronic Diversity Visa Lottery

Name *

First

Middle

Last

Gender *

Male
Female

Birth date *

City where you were born *

Country where you were born *

Passport number *

Passport issuance country *

Passport expiration date *

Upload photograph(s) *

In JPEG (.jpg) file format, equal to or less than 240 kB (kilobytes) in file size, in a square aspect ratio (height must equal width), 600×600 pixels in dimension

Current Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone number *

Email address *

Highest level of education *

Current marital status *

Number of children

DV-2023

ONLINE BOOKING FORM

IMPORTANT: please double check your photograph, failure to submit a photograph that meets DV requirements could result in the disqualification of your application. Review DV photo requirements at this link.

Child 2

Child 3

Child 4