Credit Card: (Required) Visa Master Card Discover Card American Express

Cardholder Name: (Required)

Card Number: (Required)

Expiration Month: (Required) Expiration Year: (Required)

NOTE: If you do not wish to send credit card information over the web,
please print and fax this application to 949-651-1955, or mail it to:
American Immigration and Visa Law Offices
2102 Business Center Drive, Suite 130
Irvine, California 92612-1012

Male Female

First Name: (Required)

Middle Name:

Last Name: (Required)

E-Mail Address: (Required)

City of Birth: (Required)

State/Province of Birth:

Country of Birth: (Required)

Date of Birth (dd/mm/yy): (Required)

Mailing Address of Applicant:

Telephone: Fax:

Spouse and children under 21 years of age: (Last Name, First Name, Date of Birth (dd/mm/yy), State/Province, Country of Birth, and Relationship (for example husband, wife, son, and daughter))
Example:
Habibi          Mohammed             17/9/98               Punjab                   Pakistan                     Son

Spouse's Mailing Address, Telephone Number, and Fax: ( If Different Than The Applicant )

Special Circumstances:

If you are not a native of a country whose nationals are eligible to participate in the lottery, but you
were born in a country of which neither of your parents were a native, you may be charged to the
country of birth of either parent. If this applies to you, please indicate the country to which you wish
to be charged: and explain your circumstances below.