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Electronic Diversit Visa Lotter

OMB Con ol N mbe : 1405-0153 Fo m: DS-5501 E pi e : 05/31/2012 E ima ed B den: 30 min e

ELECTRONIC DIVERSITY VISA ENTRY FORM

Submission Confirmation: Entr Received

Success!

Yo en fo he 2013 Di e i EDT. Plea e do NOT clo e hi Confi ma ion N mbe . Entrant Name: Confirmation Number: Year of Birth: Digital Signature: Thank o fo o en

Vi a Lo e p og am a ecei ed on F ida , No embe 4, 2011 a 2:26:45 PM indo n il o ha e p in ed hi confi ma ion page o made a eco d of o

CENTEIO, SANTA VIEIRA PINA 201331AHEDHTJRY2 1977 DEBF6BA2B88FC0C547B3BCAD9D3C9C0291560A00 Vi a Lo e .

fo he 2013 Di e i

Please either print this page or make a record of the confirmation number before closing this window. You will not be able to retrieve this number after ou close this window. Yo m e ain o confi ma ion n mbe in o de o check o en a ia h p:// .d lo e . a e.go /ESC/ be een Ma 1, 2012 and Ap il 30, 2013 o de e mine he he o en a elec ed fo f he p oce ing in he 2013 Di e i Vi a Lo e . Yo ill be REQUIRED o en e o confi ma ion n mbe in combina ion i h o he pe onal info ma ion in o de o check on o en a . Selectees will not receive selectee notifications or letters b regular postal mail from the Kentuck Consular Center (KCC). Do not submit additional Entr Forms with this person as the Primar Entrant! Multiple entries will disqualif the Entrant from participation in the 2013 Diversit Visa Lotter .

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