| *
First and Last Name: |
|
| *
Date of Birth: |
(DD/MM/YYYY) |
| *
City and Country of Birth: |
|
| * Education Level (last school graduated):
|
|
| *
Nationality: |
|
|
| |
| Your
Wife's info, "please skip
this part if you are not married." |
| * First and Last Name: |
|
| * Date of Birth: |
(DD/MM/YYYY) |
| * City and Country of Birth: |
|
| * Education Level (last school graduated):
|
|
| * Nationality : |
|
|
|
| Please
give us your children's info. here. (Each
children must be 21 years old or less and non-married)
"Please
skip this part, If
you don't have any children." |
|
Your
1st Child's info. |
| * First and Last Name: |
|
| * Date of Birth: |
(DD/MM/YYYY) |
| * City and Country of Birth: |
|
| |
|
| Your
2nd Child's info. |
| * First and Last Name: |
|
| * Date of Birth: |
(DD/MM/YYYY) |
| * City and Country of Birth: |
|
| |
|
| Your
3rd Child's info. |
| * First and Last Name: |
|
| * Date of Birth: |
(DD/MM/YYYY) |
| * City and Country of Birth: |
|
| |
|
| Your
4th Child's info. |
| * First and Last Name: |
|
| * Date of Birth: |
(DD/MM/YYYY) |
| * City and Country of Birth: |
|
| |
|
| Additional
Children. |
If you have additional children
please enter their names here.
|
|
|
| Your
Mailing Address info. |
| *
Adress : |
This
address will be as your communication address so make sure
to write it correctly and double check it before you submit.
|
| *
City : |
|
| *
Country : |
|
|
Zip Code : |
( if not known, you
may leave this blank ) |
| *
Phone :
(Please include your area
code first) |
You'll
be reached from this number
|
| *
Cell phone or any additional number : |
|
| *
E-Mail : |
|
| |
For how many
years should we repeat your application?
(U.S.
Government allows you to file a seperate application for
your wife which will double your chances of winning, for
a small addition in price, it will increase your chances
a great deal, however you don't have to file for your
wife if you do not wish, even if you are married)
|
|
1
year
39 USD .
1 year w/wife
(with a seperate
application for your wife,
increase your chances another notch if
you are married)
2
years
(SAVE!! $18,
repeat your application for one more year and increase
your chances)
60 USD
2 years w/wife
(SAVE!!
$39with a seperate application
for your wife, increase your chances
another notch if you are married)
69 USD
3
years
(SAVE!!
$37, repeat your application for two more years
and increase your chances even more)
80 USD
3 years w/wife
(SAVE!!
$58 with a seperate application for your wife,
increase your chances another notch if your are
married)
89 USD
4
years (**BEST VALUE)
(SAVE!!
$66, repeat your application for three more years
and increase your chances even more)
90 USD
4 years w/wife
(SAVE!!
$97 with a seperate application for your wife,
increase your chances another notch
if your are married)
99 USD
5
years (**BEST PERFORMANCE)
(SAVE!!
$85, repeat your application for four more years
and increase your chances even more)
110 USD
5 years w/wife (**BEST
PERFORMANCE/VALUE)
(SAVE!!
$126 with a seperate application for your wife,
increase your chances another notch
if your are married)
119 USD |
| |
| Payment
Details : (You
must enter your credit card information for us to be able
to process your application without payment your application
will be rejected by the system, so please don't leave
this part blank and submit.) |
| *
Name
of Person on Credit Card
: |
|
| *
Credit card number : |
|
| *
Expiration date : |
Mo
:
Yr :
|
| *
CV2 No : |
What is CV2? |
Credit
card security is protected by
verisign
this
information is never kept in our database or anywhere
so it is
100% secure.
    Secure
E@Commerce
|