OMB Control Numbe

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ELECTRONIC DIVERSITY VISA ENTRY FORM Expires
Estimated Burden

Submission Confirmation: Application Received

Success!

A Diversity Visa 2009 Lottery Entry Form was received on Wednesday, November 28, 2007 at 8:49
EST and has been entered into the system. Please print this page for your personal records. You w
need to use your browser's print button for this. Your application is now complete, after printing you
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Applicant Name: DHALI, MD SHAHABUDDIN

Birth Date: Tuesday, January 02, 1968

Eligibility Country: Bangladesh

Do not submit additional Entry Forms with
person as the Primary Applicant!

Multiple entries will disqualify the applicant from participation in the Lottery.

PAPERWORK REDUCTION ACT

*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 data, providing the
information required, and reviewing the final collection. In accordance with
5 CFR 1320 5(b), persons are not required to respond to the collection of
this information unless this form displays a currently valid OMB control
number. Send comments on the accuracy of this estimate of the burden and
recommendations for reducing it to: U.S. Department of State (A/ISS/DIR)
Washington, D.C. 20520.

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