ELECTRONIC DIVERSITY VISA ENTRY FORM

OMB Control Number: 1405-0153
Form:
DS-5501
Expires: 05/31/2010
Estimated Burden: 30 minutes

Part One - Entrant Information

1. Name

a. Last/Family Name

No
Last/Family Name

b. First Name

No First
Name

c. Middle Name

No
Middle Name

2. Birth Date

Select Day... 1
2 3 4 5 6
7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Select Month... January February March April May June July August September October November December

Select Year... 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 1899 1898 1897 1896 1895 1894 1893 1892 1891 1890 1889 1888 1887 1886 1885 1884 1883 1882 1881 1880

3. Gender

Male

Female

4. City Where You Were Born

Birth
City/Town Unknown

5. Country Where You Were Born

Select A Country... Afghanistan Albania Algeria Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and
Herzegovina Botswana Brazil British Virgin
Islands Brunei Bulgaria Burkina Faso
Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African
Republic Chad Chile China, People's Republic
Of China-Taiwan Christmas Island Cocos
Islands Colombia Comoros Congo, Democratic Republic of
The Congo, Republic of The Cook Islands Costa Rica
Cote d'Ivoire Croatia Cuba Cyprus Czech Republic
Denmark Djibouti
Dominica Dominican
Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea
Estonia Ethiopia
Falkland Islands Fiji Finland France French Guiana
French Polynesia French
Southern and Antarctic Lands Gabon
Gambia Gaza Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guinea Guinea-Bissau Guyana
Haiti Honduras
Hong Kong Special Administrative Region
Hungary Iceland
India Indonesia
Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania
Luxembourg Macau Special
Administrative Region Macedonia
Madagascar Malawi
Malaysia Maldives
Mali Malta Marshall Islands Martinique Mauritania
Mauritius Mexico
Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands
Antilles New Caledonia New Zealand Nicaragua
Niger Nigeria
Niue North Korea
Northern Ireland Norway Oman Pakistan Palau Panama Papua New Guinea
Paraguay Peru
Philippines Pitcairn Poland Portugal Qatar Reunion Romania Russia Rwanda Saint Kitts and Nevis Saint
Lucia Saint Vincent and the
Grenadines Samoa San Marino Sao Tome and
Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone
Singapore Slovakia
Slovenia Solomon
Islands Somalia South Africa South Korea
Spain Sri Lanka
St. Helena St. Pierre and
Miquelon Sudan Suriname Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago
Tunisia Turkey
Turkmenistan Turks And
Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United
Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City
Venezuela Vietnam
Wallis and Futuna West
Bank Western Sahara Yemen Zambia Zimbabwe

6. Country of Eligibility for the DV Program

Your country of eligibility will
normally be the same as your country of birth. Your country of eligibility
is not related to where you live. If you were born in a country
that is not eligible for the DV program, please go to Explanation of Country of Eligibility {this link will open in a new window} to see if there is
another option available in your case.

Are you claiming eligibility based on the country where you were
born?

Yes

No

If not, you must enter the country from which you are claiming
eligibility.

Select A Country... Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda
Argentina Armenia
Aruba Australia
Austria Azerbaijan
Bahamas Bahrain
Bangladesh Barbados
Belarus Belgium
Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brunei Bulgaria Burkina Faso
Burma Burundi Cambodia Cameroon Cape Verde Central African
Republic Chad Chile China-Taiwan Christmas Island Cocos
Islands Comoros Congo, Democratic Republic of The Congo, Republic of The Cook
Islands Costa Rica Cote d'Ivoire Croatia
Cuba Cyprus
Czech Republic Denmark Djibouti Dominica Egypt Equatorial Guinea Eritrea
Estonia Ethiopia
Fiji Finland
France French
Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Greece Greenland Grenada Guadeloupe Guinea Guinea-Bissau Guyana
Honduras Hong Kong Special
Administrative Region Hungary
Iceland Indonesia
Iran Iraq Ireland Israel Italy Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg
Macau Special Administrative Region Macedonia Madagascar
Malawi Malaysia
Maldives Mali
Malta Marshall
Islands Martinique Mauritania Mauritius Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles New
Caledonia New Zealand Nicaragua Niger Nigeria Niue North Korea Northern
Ireland Norway Oman Palau Panama Papua New Guinea
Paraguay Portugal
Qatar Reunion
Romania Russia
Rwanda Saint Kitts and
Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi
Arabia Senegal Serbia Seychelles Sierra Leone Singapore
Slovakia Slovenia
Solomon Islands Somalia South Africa Spain Sri Lanka St. Pierre and Miquelon Sudan Suriname Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia
Turkey Turkmenistan Tuvalu
Uganda Ukraine
United Arab Emirates Uruguay Uzbekistan Vanuatu Vatican City
Venezuela Wallis and
Futuna Western Sahara Yemen Zambia Zimbabwe

7. Entrant Photograph

Photographs must be submitted at the time of E-DV entry.
Photographs that do not comply with all specifications, including but not
limited to recency of the photos, composition of the photos, and
unacceptable backgrounds are grounds for disqualification of the entire
entry. Any manipulation of photographs that alters the facial
characteristics is grounds for disqualification of the entire entry. See
examples on the Photo Validation {this link will open in
a new window} page.

Please refer to the Instructions for the 2010 Diversity Immigrant Visa
Program (DV-2010) for technical specifications and compositional
specifications for the digital image.

You will use one of the following methods to enter the image into eDV:

Take a new digital image.

Use a digital scanner to scan a submitted photograph.

Link
to photo instructions/photo validation page {this link
will open in a new window}

Photograph File Name

If you know the location in the computer and the
name of the file which is storing the photograph, enter in the box to the
left of the 'Browse' button. If you are not sure of the location in the
computer or the name of the file, clicking the 'Browse' button will allow
you to look for and choose the file which is storing the photograph, and
after you choose the file its name will appear in the box above.

8. Mailing Address

8a. In Care Of

8b. Address Line 1

8c. Address Line 2

8d. City/Town

8e.
District/County/Province/State

8f. Postal Code/Zip
Code

No
Postal Code/Zip Code

8g. Country

Select A Country... Afghanistan Albania
Algeria Andorra
Angola Anguilla
Antigua and Barbuda Argentina Armenia
Aruba Australia Austria
Azerbaijan Bahamas Bahrain
Bangladesh Barbados Belarus
Belgium Belize Benin Bermuda Bhutan
Bolivia Bosnia and
Herzegovina Botswana Brazil British Virgin
Islands Brunei Bulgaria Burkina Faso
Burma Burundi
Cambodia Cameroon Canada
Cape Verde Cayman
Islands Central African Republic
Chad Chile
China, People's Republic Of China-Taiwan Christmas
Island Cocos Islands Colombia Comoros
Congo, Democratic Republic of The
Congo, Republic of The Cook Islands Costa
Rica Cote d'Ivoire Croatia Cuba Cyprus Czech
Republic Denmark Djibouti Dominica
Dominican Republic Ecuador Egypt El Salvador Equatorial
Guinea Eritrea Estonia Ethiopia
Falkland Islands Fiji Finland France French Guiana
French Polynesia French Southern and Antarctic Lands Gabon Gambia Gaza Georgia Germany Ghana Gibraltar Greece
Greenland Grenada Guadeloupe
Guatemala Guinea Guinea-Bissau
Guyana Haiti
Honduras Hong Kong
Special Administrative Region Hungary Iceland
India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan
Kenya Kiribati Kosovo
Kuwait Kyrgyzstan Laos
Latvia Lebanon Lesotho
Liberia Libya
Liechtenstein Lithuania Luxembourg
Macau Special Administrative Region
Macedonia Madagascar Malawi
Malaysia Maldives Mali Malta Marshall
Islands Martinique Mauritania Mauritius
Mexico Micronesia,
Federated States of Moldova
Monaco Mongolia Montenegro
Montserrat Morocco Mozambique
Namibia Nauru
Nepal Netherlands Netherlands
Antilles New Caledonia New Zealand Nicaragua Niger
Nigeria Niue
North Korea Northern
Ireland Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru
Philippines Pitcairn Poland
Portugal Qatar Reunion Romania Russia
Rwanda Saint Kitts and
Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino
Sao Tome and Principe Saudi Arabia Senegal
Serbia Seychelles Sierra
Leone Singapore Slovakia Slovenia
Solomon Islands Somalia South Africa
South Korea Spain Sri Lanka
St. Helena St. Pierre
and Miquelon Sudan Suriname Swaziland
Sweden Switzerland Syria
Tajikistan Tanzania Thailand
Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey
Turkmenistan Turks
And Caicos Islands Tuvalu
Uganda Ukraine United Arab
Emirates United Kingdom
United States Uruguay Uzbekistan
Vanuatu Vatican
City Venezuela Vietnam Wallis and
Futuna West Bank Western Sahara Yemen
Zambia Zimbabwe

(NOTE: This is the
address that will be used to notify you if you are
selected.)

9. Country Where You Live Today

Select A Country... Afghanistan Albania Algeria Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and
Herzegovina Botswana Brazil British Virgin
Islands Brunei Bulgaria Burkina Faso
Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African
Republic Chad Chile China, People's Republic
Of China-Taiwan Christmas Island Cocos
Islands Colombia Comoros Congo, Democratic Republic of
The Congo, Republic of The Cook Islands Costa Rica
Cote d'Ivoire Croatia Cuba Cyprus Czech Republic
Denmark Djibouti
Dominica Dominican
Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea
Estonia Ethiopia
Falkland Islands Fiji Finland France French Guiana
French Polynesia French
Southern and Antarctic Lands Gabon
Gambia Gaza Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guinea Guinea-Bissau Guyana
Haiti Honduras
Hong Kong Special Administrative Region
Hungary Iceland
India Indonesia
Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania
Luxembourg Macau Special
Administrative Region Macedonia
Madagascar Malawi
Malaysia Maldives
Mali Malta Marshall Islands Martinique Mauritania
Mauritius Mexico
Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands
Antilles New Caledonia New Zealand Nicaragua
Niger Nigeria
Niue North Korea
Northern Ireland Norway Oman Pakistan Palau Panama Papua New Guinea
Paraguay Peru
Philippines Pitcairn Poland Portugal Qatar Reunion Romania Russia Rwanda Saint Kitts and Nevis Saint
Lucia Saint Vincent and the
Grenadines Samoa San Marino Sao Tome and
Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone
Singapore Slovakia
Slovenia Solomon
Islands Somalia South Africa South Korea
Spain Sri Lanka
St. Helena St. Pierre and
Miquelon Sudan Suriname Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago
Tunisia Turkey
Turkmenistan Turks And
Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United
Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City
Venezuela Vietnam
Wallis and Futuna West
Bank Western Sahara Yemen Zambia Zimbabwe

10. Phone Number

Optional

11. E-mail Address

Electronic delivery of DV
correspondence may be offered in the near future. Please enter an email
address in the box below if you would prefer to receive correspondence
electronically.

Optional

12. What is the highest level of education you have achieved, as of
today?

Primary
school only

University
Degree

High
School, no degree

Some
Graduate Level Courses

High
School degree

Master
Degree

Vocational
School

Some
Doctorate Level Courses

Some
University Courses

Doctorate
Degree

You must have a minimum of a high school diploma
reflecting the completion of a full course of study (vocation schools or
equivalency degrees are not acceptable) or be a skilled worker in an
occupation that requires at least two years of training or experience to
qualify (visit http://online.onetcenter.org/ {this link
will open in a new window} to see if your occupation qualifies) for
a Diversity Visa.

13. What is your current marital status?

Unmarried

Married

Divorced

Widowed

Legally
Separated

Legal separation means that a court has formally
declared that you and your spouse are legally separated. Legal separation
means that your spouse would not be eligible to immigrate as your
derivative.

14. Number of Children

Children include all biological children, legally adopted children,
and stepchildren who are unmarried and under the age of 21 on the date
that you submit your entry. Failure to include all children or inclusion
of children who are not your biological children, legally adopted
children, and stepchildren (regardless of whether they live with you
and/or intend to apply for a visa as your derivative) is grounds for
disqualification of the entire entry.

Legal Permanent Residents (LPR) and American Citizens should not be
included.

PAPERWORK REDUCTION ACT

*Public
reporting burden for this collection of information is estimated to
average
30 minutes per response, including time required for searching
existing data
sources, gathering the necessary data, providing the
information required,
and reviewing the final collection. In accordance with
5 CFR 1320 5(b),
persons are not required to respond to the collection of
this information
unless this form displays a currently valid OMB control
number. Send comments
on the accuracy of this estimate of the burden and
recommendations for
reducing it to: U.S. Department of State (A/ISS/DIR)
Washington, D.C. 20520.