Form DSP-122 Supplemental Registration for the Diversity Immigrant Vi

U.S. Department of State

SUPPLEMENTAL REGISTRATION FOR
THE DIVERSITY IMMIGRANT VISA PROGRAM

OMB APPROVAL NO. 1405-0098
EXPIRATION DATE: xxxx/xxxx
ESTIMATED BURDEN: 30 MINUTES
*See Page 2

INSTRUCTIONS
The following is a supplemental registration form for the Diversity Immigrant Visa Program under Section 203(c) of the Immigration and Nationality Act.
Clearly print or type all answers in the English language. Answer all questions.
Using the enclosed self-adhesive return address label, immediately send this form along with Form DS-230 to: Diversity Immigrant Visa Program,
Kentucky Consular Center, 3505 N. Highway 25W, Williamsburg, KY 40769. Failure to follow instructions will disqualify your application.
You will be notified by mail of your appointment date, therefore the answer to question No. 3 must be accurate.
1. Name (Last, First, MI.)

2. Rank Order Number (Case Number on Envelope)

3. Current Mailing Address (Address at which you receive your mail. Give any change of mailing address here.)

Telephone Number (Optional)
4. Name of United States Consular Office where you would like to Process your Application
This will usually be the consular office nearest the place you live. However, please note that some U.S. Embassies and Consulates do not process
immigrant visas. If you are not sure whether the U.S. Embassy or Consulate nearest you processes immigrant visas, or if you do not know which is the
U.S. Embassy or Consulate nearest you, please list the city and country where you live. If you live in the United States and plan to adjust status with
the United State Citizenship and Immigration Services (USCIS) please list "USCIS"; if you live in the United States but you intend to return abroad to be
interviewed, please list the U.S. Embassy or Consulate that processes immigrant visas for the area where you lived before you came to the United
States.

5. The Country you Listed as your Native Country on your Diversity Visa Program Application
In most cases, this will be the country where you were born. You may also claim the country of birth of your husband or wife. In addition,
you may claim the country of birth of either of your parents, if neither of your parents lived in, or was born in, the country where you were born.

6. Education
a. Check the highest level of education completed.
High School, No Degree

High School Diploma

Vocational School

College, No Degree

University Degree

Advanced Degree

Other
b.

Names and Addresses of all Schools, Colleges, and Universities Attended (Include Trade and Vocational Schools):
Name of Educational Institution

From (mm-yyyy)

--

To (mm-yyyy)

Degrees(s) or Certificates(s) Received

------DSP-122
xx-xxxx

Page 1 of 2

7.

Work Experience
a.

Within the last 5 years, I have worked at least 2 years in a job that requires at least 2 years of training or experience:
Yes

No

b. Occupation - If you answered "yes" to question 7a, give the job title and describe the type of work you did. Be as specific as possible.

c. Names and addresses of your employers during the past 5 years in the work you described above, and the dates (Beginning and Ending
Months and Years) you worked for each.
Name of Employer

Address

From (mm-yyyy) --

To (mm-yyyy)

SIGNED STATEMENT
I certify that only one application was or has been submitted by me or on my behalf for this immigrant visa registration. I
further certify that I have read and understand all the questions set forth above and that the answers I have furnished on
this form are true and correct to the best of my knowledge and belief. I understand that any false or misleading statement
may result in the refusal of a visa or denial of entry into the United States.

Signature of Applicant

Date (mm-dd-yyyy)

CONFIDENTIALITY AND PAPERWORK REDUCTION ACT STATEMENTS
INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential and shall be used only for the formulation, amendment,
administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of visa records may be made available
to a court which certifies that the information contained in such records is needed in a case pending before the court.
*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 documentation, providing the information and/or documents required, and reviewing the final collection. You do not
have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden
estimate and/or recommendations for reducing it, please send them to: Legislation and Regulations Division, Visa Services-Forms, 2401 E Street, N.W.,
Washington, DC 20520-0106.

DO NOT WRITE IN THIS SPACE - FOR OFFICIAL USE ONLY
Occupation Code
DSP-122

Page 2 of 2