Electronic Diversity Visa Entry Form

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‫طلب المشاركة في قرعة الهجرة إلى أمريكا‬
ELECTRONIC DIVERSITY VISA ENTRY FORM
‫معلومات المترشح‬
‫المرحلة األولى‬
Part One - Applicant Information
‫االسم العائلي‬
‫االسم الشخصي‬
1. Name
1a. Last/Family Name
1b. First Name
__________________
_________________
2. Birth Date ‫تاريخ االزدياد‬
____/____/_______
3. Gender ‫الجنس‬
Male [ ] ‫ذكر‬
Female [ ] ‫أنثى‬
4. City Where You Were Born ‫مكان االزدياد‬
_____________________
5. Country Where You Were Born ‫_____________________ بلد االزدياد‬
6. Country of Eligibility ‫البلد الذي تشارك فيه في االنتخابات‬
‫هل تشارك في االنتخابات ببلدك مكان االزدياد‬
‫نعم‬
‫ال‬
Yes [ ]
No [ ]
Are you claiming eligibility based on your Birth Country?
If not, you must enter the country from which you are claiming eligibility.
‫إذا كانت إجابتك بال فعليك ذكر الدولة حيث تشارك في االنتخابات‬
__________________
‫خاصة‬
‫الصورة ال‬
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
1023
grounds for disqualification of the entire entry.Please refer to the Instructions for the
Diversity Immigrant Visa
1023
Program (DV-
) 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.
Photograph File Name : _________________.jpg
8. Mailing Address ‫عنوان المراسلة‬
8a. In Care Of
: ___________________________________
8b. Address Line 1: ______________________________________
8c. Address 2
: ______________________________________
: ___________________________________ ‫المدينة‬
8d. City/Town
8e. District/County/Province/State : _________________________ ‫العمالة أو االقليم‬
: _________________________ ‫الرمز البريدي‬
8f. Postal Code/Zip Code
8g. Country
: Morocco
9. Country Where You Live Today ‫_______________________ الدولة التي تعيش فيها حاليا‬
‫* يجب ملء هذا الطلب باألحرف الالتنية بدقة و أمانة و تقديمه للسيد ابراهيم ب ِزا ر ِ رقم 62 سوق إفران أ.ص. و ذلك في الموعد المحدد‬

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