Electronic Diversity

ELECTRONIC DIVERSITY VISA ENTRY FORM

Approved OMB 1405-0153
Expires: 04/30/2007
Estimated Burden: 30 minutes

Part One - Applicant Information

1. Name

1a. Last/Family Name

No Last/Family Name

1b. First Name

No First Name

1c. Middle Name

No Middle Name

2. Birth Date

3. Gender

Male

Female

4. City/Town of Birth

Birth City/Town Unknown

5. Country of Birth

6. Primary Photograph

Please refer to the Instructions for the 2006 Diversity Immigrant Visa Program (DV-2006) 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.

Specific instructions are included for both methods.

Photograph File Name
If you know the location in the computer and the name of the file which is storing the photograph, enter it 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 on the left.

7. Mailing Address

7a. In Care Of
7b. Address Line 1
7c. Address 2
7d. City/Town
7e. District/County/Province/State
7f. Postal Code/Zip Code	No Postal/Zip Code
7g. Country
(NOTE: This is the address that will be used to notify you if you are selected.)

8. Phone Number

Optional

9. E-mail Address

Optional

10. Country of Eligibility

Are you claiming eligibility based on your Birth Country?
Yes No

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

11. Are You Married?

Unmarried (no spouse info required)

Married (spouse info required)

Divorced (no spouse info required)

Widowed (no spouse info required)

Separated (spouse info required)

Legally Separated (no spouse info required)

12. Number of Children

(Unmarried and under 21 years of age)
(Legal Permanent Residents (LPR) and American Citizens should not be included)

DS-5501

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/RPS/DIR)
Washington, D.C. 20520.