SINGLE APPLICANTS - DV LOTTERY ENTRY FORM (EBM SCHOLARS STAFF)

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- Step 1 of 2

APPLICATION NUMBER *

MPESA PAYMENT CONFIRMATION CODE *

NAME OF STAFF FILLING OUT THE FORM *

PLEASE MAKE SURE CUSTOMER REVIEWS AND APPROVES THE INFORMATION FILLED BEFORE SUBMISSION

Part One - Entrant Information

1. Name *

First

Middle

Last

2. Gender *

3. Date of Birth (Month, Date, Year) Write month in words, example February 10, 1999 *

4. City Where You Were Born *

5. Country You Were Born *

6. Country of Eligibility (Write country you were born, unless you were born in a country not eligible) *

7. Entrant Photograph (Upload all photos you need me to use. Each photo indicate the name of the person, if you have a a family). EBM SCHOLARS Team will edit for you to put in proper measurements.

Drag & Drop Files, Choose Files to Upload You can upload up to 20 files.

9. City Where You Live Today *

9. Country Where You Live Today *

10. WhatsApp Phone Number *

11. E-Mail Address *

Email

Confirm Email

12. What is the highest level of education you have achieved, as of today? SELECT ONE *

Primary School Only
High School, no degree
High School Degree
Vocational School
Some University Courses
University Degree
Some Graduate Level Courses
Master's Degree
Some Doctorate Level Courses
Doctorate Degree

13. What is your current marital status? *

Unmarried (SINGLE)
Married and my spouse is NOT a U.S. Citizen or Green Card Holder
Married and my spouse IS a U.S. Citizen or Green Card Holder
Divorced
Widowed
Legally Separated by the Court Order

14. Number of Children (Write 0) *

Number Must Be ZERO. For any person with a child or children, Fill Out FAMILY Form

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