Part One - Main Applicant (Complete this section) Click here for more Guidelines

As shown on
Last/Family Name: *
passport

As shown on
First Name: *
passport

As shown on
Middle Name:
passport

Date of Birth: * dd/MM/yyyy day_month_year e.g.15/06/1979

Gender: * Please select... Your Gender?

Your Highest Level of Education?
Highest Level of Education: * Please select....

City or town where you were

City/ Town of Birth: *
born
 Please select.... Your Country Of Birth? Country where you were born
Country of Birth: *
(current country name)

An email address to
Email: *
which you have direct access.
If your entry is selected and
you respond to

Full name to receive your

In Care Of (Full Name): *
winning notification

Full Mailing address to receive

Address1: *
your winning notification

Address 2:

City or town where you live

City/Town: *
today

District/County/Province/State: *
Postal Code/ZipCode:
Country: *
Phone Number: *
Country of Eligibility: *
Person you Claim Eligibility from
- Complete only if relevant:
Marital Status: *
Number of Children: *
Country where you live
Please select.... Country You Live In?
today
Contact number to be
contacted if necessary
Use Country of Birth; if excluded,
Please Select... Your Country Of Eligibility?
put Country of Eligibility & below
put the person you are claiming
eligibility from e.g.
(Spouse/Mother/Father)
Person You Claim Your Eligibility from? Must complete if born in an
Please select...
excluded country & claiming
Country Eligibility of
(Spouse/Parent)
Your Current Marital Status?
Please select....
Number of Children You Have?
Please select.... Include total of all living
unmarried children under 21
years of age
Part Two - Spouse (If required, complete this section)

(Spouse) Last/Family Name: As shown on passport

(Spouse) First Name: As shown on passport

(Spouse) Middle Name: As shown on passport

(Spouse) Date of Birth: dd/MM/yyyy day_month_year e.g.15/06/1979

(Spouse) Gender: Please select.... Your Spouse's Gender?

(Spouse) City/Town of Birth: City or town where

spouse was born

Please select.... Spouse's Country Of Birth? Country spouse was born

(Spouse) Country of Birth:
(current country name)
Part Two - Child 1 (All unmarried children under 21)

(Child1) Last/Family Name: As shown on passport

(Child1) First Name: As shown on passport

(Child1) Middle Name: As shown on passport

(Child1) Date of Birth: dd/MM/yyyy day_month_year e.g.12/03/2005

(Child1) Gender: Please select... Child1 Gender?

City/town w here child1

(Child1) City/Town of Birth:
was born

Country where child 1

(Child1) Country of Birth: Please select.... Child1 - Country Of Birth? was born (current country
name
Part Two - Child 2 (All unmarried children under 21)

(Child2) Last/Family Name: As shown on passport

(Child2) First Name: As shown on passport

(Child2) Middle Name: As shown on passport

(Child2) Date of Birth: dd/MM/yyyy day_month_year e.g.12/03/2005

(Child2) Gender: Please select.... Child2 Gender?

(Child2) City/Town ofBirth: City or town where your

child 2 was born

Country where your child 2

(Child2) Country of Birth: Please select.... Child2 - Country Of Birth?
was born (current country
name)
Part Two - Child 3 (All unmarried children under 21)

(Child3) Last/Family Name: As shown on passport

(Child3) First Name: As shown on passport

(Child3) Middle Name: As shown on passport

(Child3) Date of Birth: dd/MM/yyyy day_month_year e.g.12/03/2005

(Child3) Gender: Please select.... Child3 Gender?

(Child3) City/Town of Birth: City/tow n where child 3

was born

Country where child 3 was

(Child3) Country of Birth: Please select.... Child3 - Country Of Birth?
born (current country name)
Part Two - Child 4 (All unmarried children under 21)

(Child4) Last/Family Name: As shown on passport

(Child4) First Name: As show n on passport

(Child4) Middle Name: As show n on passport

(Child4) Date of Birth: dd/MM/yyyy day_month_year e.g.12/03/2005

(Child4) Gender: Please select.... Child4 Gender?

City/town where child

(Child4) City/Town of Birth:
4 was born

Country where child 4 was born

(Child4) Country of Birth: Please select.... Child4 - Country Of Birth? (current country name)
Part Two - Child 5 (All unmarried children under 21)

(Child5) Last/Family Name: As shown on passport

(Child5) First Name: As shown on passport

(Child5) Middle Name: As shown on passport

(Child5) Date of Birth: dd/MM/yyyy day_month_year e.g.12/03/2005

(Child5) Gender: Please select.... Child5 Gender?

City/town where child5

(Child5) City/Town of Birth:
was born

Country where child 5 was born

(Child5) Country of Birth: Please select.... Child5 - Country Of Birth? (current country name)
 Email your application form back with photos attached or Post with photos (see details below)

Attach and Email photo with

Applicant Photo: * Attach your form (max size 500kb) or Click here for more Photo Instructions
post in with your printed form)
Physical Photo Specifications
Attach and Email Spouse photo
Spouse Photo: Attach with your form (max size 500kb) or
post in with your printed form

Attach and Email Child 1 photo

Child 1 Photo: Attach with your form (max size 500kb) or
post in with your printed form

Attach and Email Child 2 photo

Child 2 Photo: Attach with your form (max size 500kb)
or post in with your printed form Digital Photo Specifications

Attach and Email Child 3 photo

Child 3 Photo: Attach with your form (max size 500kb)
or post in with your printed form

Attach and Email Child 4 photo with

Child 4 Photo: Attach your form (max size 500kb) or post in
with your printed form

Attach and Email Child 5 photo with

Child 5 Photo: Attach your form (max size 500kb) or post in
with your printed form

Attach and Email Child 6+ photoswith

Children List: Attach your form (max size 500kb) or
post in with your printed form
Payment Instructions - Use this section for Email submissions & Credit card payments only:

Complete your form, email it back with all relevant photographs attached to submissions@lottery2usa.com
make sure you include your payment ID no. (below) & email to confirm payment, to fast track your entry.
Payment Options Please Select your Payment Option here?
Payment Amount Please Select your Payment Amount here?
If you select the Credit card payment option above, click here to pay online now. Make a note of your card
Payment or Transaction Id number and provide it here:

Payment Instructions - Use this section for Email submissions with Non Credit card payments
Complete your form, email it back with all relevant photographs attached to submissions@lottery2usa.com.
Specify via email and indicate below your payment options (see the postal payment section given below).
Payment Instructions - Use this section for Postal submissions with Non Credit card payments
Payment made payable to 'Lottery2usa' & post to: Lottery2usa, Suite 412 Cumberland House, 80
Scrubs Lane, London NW10 6RF. Print your form, complete & return with all photos & relevant payment.
Payment Options (tick to select):
UK Cheque with guarantee card UK Postal Order Banker's Draft in Pound Sterling
Int'l Cheque drawn on UK bank International Money Order Bank Transfer on request

If you paying by UK cheque, must give your cheque guarantee number ____________________________
Payment Amount (tick and give total amount you are sending in):

£ 75.00 - Single Application (Single or non-married Couples may fill this form)
£ 125.00 - Joint Application (Husband/Wife) Double your chances of winning must
each fill in this form as a main applicant two versions of this form must be sent in. Payment Total
£ 10.00 - Joint Digital Photo Service - scan, crop & edit all photos to specification
£______________
£ 5.00 - Single Digital Photo Service - scan, crop & edit photos to specification
Your Submission Checklist

Email Submission & Payment Checklist

I have completed all relevant sections of my form and double checked all name spellings, dates of
birth and contact information, including my address and email.

I have attached all relevant digital photos to be emailed with my form

I have made my payment online, my payment i.d. is provided

Postal Submission & Payment Checklist

I have completed all relevant sections of my form and double checked all name spellings, dates of
birth and contact information, including my address and email.
I have enclosed all relevant photos (with name and date of birth on the back of each photo), to
be posted in, with my form.
I have included my relevant payment, made payable to 'Lottery2usa' (with my cheque guarantee
card no. if relevant), I have included my name reference if payment is made via Bank Transfer

(THIS IS A POSTAL/EMAIL SERVICE ONLY – ENTRANTS MUST EMAIL OR POST THEIR ENTRIES ONLY!
NO PERSONAL VISITORS & NO HAND DELIVERIES ALLOWED FOR THIS PROMOTION!)

Terms of Submssion: * I agree to Terms of Submission and hereby authorise Lottery2usa to make
this year's DV Lottery submission on my behalf.

I agree toget emails, Agree L2Usa can communicate withyou regarding DV Submission &related
calls,SMS/Textfrom L2usa: * information