USDVL Green Card Lottery

USDVL Organization - Credit Card Payment

Please print this page and enter your personal details where requested in CAPITAL LETTERS.

Make sure you include a recent passport photo for each person who is included in your application and that you write the name of the person in the photo in CAPITAL LETTERS on the back of each photo.

We highly recommend using our secure and encrypted online payment facility. All other payment methods are at your own discretion and risk. Please note that the USDVL Organization cannot guarantee the arrival of payments via the post due to the nature of the the mail system.

Applicant Details
First Name: Middle Name:
Family Name: Gender: Male / Female
Date Of Birth: City of Birth:
Country of Birth: Country where you live today:

Native Country:
Native Country is the same as the Country of Birth in most cases. If the Country of Birth is not eligible to participate in this year's Green Card Lottery, the applicant can nominate his Native Country to be his spouse / parents country of birth if those countries are eligible to participate.

  

Number of Children:
All natural children, as well as all legally-adopted children and stepchildren, who are unmarried and under the age of 21 (do not include children who are already U.S. citizens or Legal Permanent Residents), even if you are no longer legally married to the child’s parent, and even if the spouse or child does not currently reside with you and/or will not immigrate with you.

  

Marital Status (please circle): Single / Married / Divorced / Legally Separated / Widowed

WHAT IS THE HIGHEST LEVEL OF EDUCATION YOU HAVE ACHIEVED, AS OF TODAY? You must indicate which ONE of the following represents your own highest level of educational achievement: (please circle)

Primary school only / High school, no degree / High school degree / Vocational school /
Some university courses / University degree / Some graduate level courses / Masters degree /
Some doctorate level courses / Doctorate degree

Mailing Address
Street and number: City/Town:
District/County/Province: Zip code:
Country: Phone:
Email:
Confirm Email (Write email address again):

Spouse Details
First Name: Middle Name:
Family Name: Gender: Male / Female
Date Of Birth: City of Birth:
Country of Birth: Country where you live today:

Native Country:
Native Country is the same as the Country of Birth in most cases. If the Country of Birth is not eligible to participate in this year's Green Card Lottery, the applicant can nominate his Native Country to be his spouse / parents country of birth if those countries are eligible to participate.

  

Number of Children:
All natural children, as well as all legally-adopted children and stepchildren, who are unmarried and under the age of 21 (do not include children who are already U.S. citizens or Legal Permanent Residents), even if you are no longer legally married to the child’s parent, and even if the spouse or child does not currently reside with you and/or will not immigrate with you.

  

Marital Status (please circle): Single / Married / Divorced / Legally Separated / Widowed

WHAT IS THE HIGHEST LEVEL OF EDUCATION YOU HAVE ACHIEVED, AS OF TODAY? You must indicate which ONE of the following represents your own highest level of educational achievement: (please circle)

Primary school only / High school, no degree / High school degree / Vocational school /
Some university courses / University degree / Some graduate level courses / Masters degree /
Some doctorate level courses / Doctorate degree

Child 1 Details
First Name: Middle Name:
Family Name: Gender: Male / Female
Date Of Birth: City of Birth:
Country of Birth:  

Child 2 Details
First Name: Middle Name:
Family Name: Gender: Male / Female
Date Of Birth: City of Birth:
Country of Birth:  

Child 3 Details
First Name: Middle Name:
Family Name: Gender: Male / Female
Date Of Birth: City of Birth:
Country of Birth:  

Child 4 Details
First Name: Middle Name:
Family Name: Gender: Male / Female
Date Of Birth: City of Birth:
Country of Birth:  

Child 5 Details
First Name: Middle Name:
Family Name: Gender: Male / Female
Date Of Birth: City of Birth:
Country of Birth:  

If Applicant has more than 5 children, please attach a seperate piece of paper with the details of those children in the same way as entered in the tables above.

Credit Card Details

Select card and complete all details
Visa
MasterCard
Credit card payments must include photocopy of:

(1) Credit Card (both sides, front and back).
(2) Photo ID (passport or ID card or driving license).
Card Number: |__|__|__|__|  |__|__|__|__|  |__|__|__|__|  |__|__|__|__|
Expiration Date: |_______|_______|
Card Holder Name: |_________________________|
Security Code (Last 3 digits from back of card): |__|__|__|
Signature: |____________________________________|

Service and Fee (All prices are in Australian Dollars)

Mark with X Select your Service Price (AUD)
Your application for 1 year 49$
Your application for 2 years
69$
You & Your Husband/Wife applications for 1 year
 Double Your Chances ! 		79$
You & Your Husband/Wife applications for 2 years
 4 times more chances !		 99$
Your application for 4 years 119$
You & Your Husband/Wife applications for 4 years
 8 times more chances !		 199$
You & Your Husband/Wife applications for 10 years
 20 times more chances !		 299$

TERMS AND CONDITIONS - Alternate Payment Method Appendix

Please read the following "Alternate Payment Method Appendix" which supplements the "Terms & Conditions" specified on the www.green-card.com.au website and sign below:

  1. I accept and agree that the payment method selected and executed herein is at my own discretion and risk. I accept and agree that the USDVL Organization will not be responsible for any loss of an application that is sent in via the mail.
  2. I accept and agree that my payment to USDVL Organization is non-refundable. The purpose of the payment herein is for the review and submission of my application for the official Green Card Lottery.

I READ, ACCEPT AND AGREE:

______________________________ ________________
SIGNATURE DATE

After completing the form above and enclosing:

photocopies of both sides of your credit card and a photocopy of a photo ID (e.g. drivers license)
and passport photos of all applicants,

please mail this form to:

USDVL Organization
PO Box 56
Caulfield South
VIC 3162
AUSTRALIA