Form Dsp-122 Supplemental Registration For The Diversity Immigrant Visa Program (Page 2 of 2) in pdf

Form Dsp-122 Supplemental Registration For The Diversity Immigrant Visa Program Page 2

7. WORK EXPERIENCE

a. Within the last 5 years, I have had at least two years of work experience in an occupation which requires at least two years of training or

experience:

Yes

b. Occupation - Give a job title and describe in detail the specific type of work performed in the occupation referred to in 7a.

(Examples of

acceptable entries are "physicist, registered nurse, or tool and die maker." Entries such as scientific researcher, hospital worker, manager

or assistant are not acceptable).

c. Name(s) and address(es) of employer(s) during past five years in above occupation and inclusive dates employed by each:

NAME OF EMPLOYER

ADDRESS

FORM(Month/Year) - TO

(Month/Year)

SIGNED STATEMENT

I certify that only one application was or has been submitted by me or on my behalf for this immigrant visa registration. I further

certify that I have read and understand all the questions set forth above and that the answers I have furnished on this form are true

and correct to the best of my knowledge and belief. I understand that any false or misleading statement may result in the refusal of a

visa or denial of entry into the United States.

Signature of Applicant

Date

DO NOT WRITE IN THIS SPACE - FOR OFFICIAL USE ONLY

Occupation Code:

*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. Send comments on the

accuracy of this estimate of the burden an recommendations for reducing it to: Department of State (OIS/RA/DIR) Washington, D.C. 20520-0264,

and to the Office of information and Regulatory Affairs, Office of Management and Budget, Paperwork Reduction Project (1405-0098), Washington,

D.C. 20503.

FORM DSP-122 (BACK)

5-97

Form Dsp-122 Supplemental Registration For The Diversity Immigrant Visa Program Page 2