DV-2004 ENTRY FORM (EMAIL TO info @ immigrationandvisas.com (<-remove spaces) or mail it to Immigration and Visas Int'l with appropriate fees)
1. FULL NAME:	_________________________________________
				LAST(surname/family) FIRST MIDDLE
2. DATE OF BIRTH:	_________________________________________
				Day, Month, Year

PLACE OF BIRTH:	_________________________________________
				City/Town, District/Country/Province, Country
3. APPLICANT'S NATIVE COUNTRY IF DIFFERENT FROM COUNTRY OF BIRTH:

	_________________________________________

	_________________________________________
4. NAME, DATE AND PLACE OF BIRTH OF THE APPLICANT'S SPOUSE AND CHILDREN (IF ANY):
Attach information on additional child(ren) as necessary
	_________________________________________________________________
	Spouse's Name	Date of birth (day/Month/yr)		Place of birth

	_________________________________________________________________	
	Child's Name	Date of birth (day/Month/yr)		Place of birth

	_________________________________________________________________	
	Child's Name	Date of birth (day/Month/yr)		Place of birth

	_________________________________________________________________		
	Child's Name	Date of birth (day/Month/yr)		Place of birth
5. FULL MAILING ADDRESS:

	_________________________________________________________________	

	PHONE NUMBER: 	____________________________________________	

6. PHOTOGRAPH:
Attach a recent (less than 6 months old)
1.5 inches (37mm) square photograph (not
a photocopy) with the applicant's name
printed on the back. By using clear tape
(no staples or paperclips).

SIGNATURE: 	_________________________________________________________________	

(Failure to PERSONALLY sign the entry will disqualify the applicant.)

Mail it to:

Include Fees of US$ 75.
Immigration and Visas Int'l
21 Clyde Road, Suite 201
Somerset, NJ 08873-5043
       USA

Phone: 1-732-873-9600
Fax::    1-732-873-9787