1. FULL NAME:___________________________ ____________ ____________________
LAST (surname/family) Middle Name FIRST Name
2. DATE OF BIRTH:____________________________
Day, Month, Year
PLACE OF BIRTH: ____________________________________________________________________
City/Town, District/County/Province, Country
3. APPLICANT'S NATIVE COUNTRY IF DIFFERENT FROM COUNTY OF BIRTH:
____________________________________________________________________________________
(See "REQUIREMENTS" section for more information on this item.)
4. NAME, DATE AND PLACE
OF BIRTH OF THE APPLICANT'S SPOUSE AND CHILDREN (IF ANY)
_______________________
____________________
_____________________
Name
Date of birth
Place of birth
(day,month,year)
_______________________
____________________
_____________________
Name
Date of birth
Place of birth
(day,month,year)
_______________________
____________________
_____________________
Name
Date of birth
Place of birth
(day,month,year)
_______________________
____________________
_____________________
Name
Date of birth
Place of birth
(day,month,year)
_______________________
____________________
_____________________
Name
Date of birth
Place of birth
(day,month,year)
_______________________
____________________
_____________________
Name
Date of birth
Place of birth
(day,month,year)
If space is
insufficient, attach information on additional child(ren) as necessary.
NOTE: Polygamy is forbidden in the United States. Only one wife may be
included on application.
5. FULL MAILING
ADDRESS:
(Street Number, Street Name, City or Town, State or Province,
Country). If your country does not have street numbers, provide your
P.O. Box and all the necessary address information.
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
6. PHOTOGRAPH:
(Attach a recent, preferably less than 6 months old, photograph of the
applicant, 1.5 inches (37 mm) square in size, with the applicant's name printed
on the back. The photograph (not a photocopy) should be attached to the
entry with clear tape--DO NOT use staples or paperclips, which
can jam the mail processing equipment.)
7. SIGNATURE:
________________________________________________________
Applicant must personally sign the application. Failure to personally
sign the entry will disqualify the applicant. |
