Form Dsp-122 - Supplemental Registration For The Diversity Visa - Dsp122 Page 2

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Work Experience

a. Within the last 5 years, I have worked at least 2 years in a job that requires at least 2 years of training or experience:

Yes

b. Occupation - If you answered "yes" to question 7a, give the job title and describe the type of work you did. Be as specific as possible.

c. Names and addresses of your employers during the past 5 years in the work you described above, and the dates (Beginning and Ending

Months and Years) you worked for each.

From (mm-yyyy) --

Name of Employer

Address

To (mm-yyyy)

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 (mm-dd-yyyy)

CONFIDENTIALITY AND PAPERWORK REDUCTION ACT STATEMENTS

INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential and shall be used only for the formulation, amendment,

administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of visa records may be made available

to a court which certifies that the information contained in such records is needed in a case pending before the court.

*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 documentation, providing the information and/or documents required, and reviewing the final collection. You do not

have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden

estimate and/or recommendations for reducing it, please send them to: Legislation and Regulations Division, Visa Services-Forms, 2401 E Street, N.W.,

Washington, DC 20520-0106.

DO NOT WRITE IN THIS SPACE - FOR OFFICIAL USE ONLY

Occupation Code

DSP-122

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