PRINT CLEARLY:
| Last Name:____________________ | First Name:____________________ |
| Middle
Initial:______ School, Ocuppation_________________________ Date of birth: M:_____D:___Y:______ |
City/Town: ____________________ |
| Prov/State: ____________________ | Country: ______________________ |
| Spouse's name:____________________ | ChildName_________________________ Born: M___D____Y_____ |
| Postal Address for the Lottery Application: | ChildName________________________Born: M___D____Y_____ |
| Street:__________________________Apt.#___________Floor:________ | |
| City/Town:_____________________ | Postal Code:__________ |
| Prov./State:_____________________ | Country
of Residence: _____________________ |
| e-mail Address:____________________ | Tel.#:___________________ |
| Choice of nationality of spouse? (Native).___________________(See definition) | |
| I am attaching My US Dollar payment of $ 30.00 for Myself, $ 50.00 for more of one person. | If more space is needed, write in the back of the aplication. |
| Payment
at the Order of: Sam Moss Productions |
Personal Check:_____________over US Bank. |
| Mail
to: Sam Moss Productions Immigration Desk 939 Donner Ct. Santa Maria, CA 93454-USA |
|
| Send your applications, all the applicants photos and payment, in a # 10 envelope, Air Mail Certified, do not send more of two person's applications for security reasons. If want to send payment in cash, witch we do not recommend, use a dark envelope, so money can not be seen through.Click here for our address. | |