Middle name ,Last/Family Name, First Name - FULL NAME(1
ﺍﺳﻢ ﮐﺎﻣﻠﺘﻮﻥ ﺍﻭﻝ ﻧﺎﻡ ﺧﺎﻧﻮﺍﺩﮔﯽ ﺑﺎ ﺗﻤﺎﻡ ﭘﺴﻮﻧﺪ ﻭ ﭘﻴﺸﻮﻧﺪﻫﺎﺵ ﺑﻌﺪ ﮐﺎﻣﺎ ﺍﺳﻢ ﮐﻮﭼﻴﮑﺘﻮﻥ )ﺩﻗﺖ ﮐﻨﻴﺪ ﮐﻪ
ﺍﺳﭙﻠﺶ ﺩﻗﻴﻘﺎ ﻫﻤﻮﻧﯽ ﺑﺎﺷﻪ ﮐﻪ ﺗﻮ ﭘﺎﺳﭙﻮﺭﺗﺘﻮﻧﻪ( ﺑﻌﺪ ﻧﺎﻡ ﻭﺳﻂ )ﺍﮔﻪ ﺩﺍﺭﯾﺪ(
Year ,Day, Month - DATE OF BIRTH (2
ﺗﺎﺭﯾﺦ ﺗﻮﻟﺪ ﺭﻭﺯ ﺑﻌﺪﺍ ﻣﺎﻩ ﺑﻌﺪ ﺳﺎﻝ )ﺑﺎﺯ ﻫﻢ ﺩﻗﺖ ﮐﻨﻴﺪ ﮐﻪ ﺩﻗﻴﻘﺎ ﻫﻤﻮﻧﯽ ﺑﺎﺷﻪ ﮐﻪ ﺗﻮ ﭘﺎﺳﭙﻮﺭﺗﺘﻮﻧﻪ(
Male or Female - GENDER(3
ﺟﻨﺴﻴﺖ ﻣﺮﺩ ﯾﺎ ﺯﻥ
CITY WHERE YOU WERE BORN (4
ﺷﻬﺮ /ﺷﻬﺮﺳﺘﺎﻥ ﮐﻪ ﺍﻭﻧﺠﺎ ﺑﻪ ﺩﻧﻴﺎ ﺍﻭﻣﺪﯾﺪ
The name of the country should be that which is - COUNTRY WHERE YOU WERE BORN (5
currently in use for the place where you were born
ﮐﺸﻮﺭی ﮐﻪ ﺍﻭﻧﺠﺎ ﺑﻪ ﺩﻧﻴﺎ ﺍﻭﻣﺪﯾﺪ ﺑﺮﺍی ﻧﺎﻡ ﻛﺸﻮﺭ ﻣﺤﻞ ﺗﻮﻟﺪ ﻣﺘﻘﺎﺿﯽ ﺑﺎﻳﺴﺘﯽ ﻧﺎﻡ ﺍﻣﺮﻭﺯی ﺁﻥ ﻛﺸﻮﺭ ﺫﻛﺮ ﺑﺸﻪ.
Your country - COUNTRY OF ELIGIBILITY OR CHARGEABILITY FOR THE DV PROGRAM (6
oeligibility will normally be the same as your country of birth. Your country of eligibility
is not related to where you live. If you were born in a country that is not eligible for the DV
instructions to see if there is another option for country of program, please review the
chargeability available for you
ﮐﺸﻮﺭ ﻭﺍﺟﺪ ﺷﺮﺍﻳﻂ ELIGIBILITY OR CHARGEABILITY ،ﮐﻪ ﺑﻪ ﺻﻮﺭﺕ ﻧﺮﻣﺎﻝ ﻫﻤﻮﻥ ﮐﺸﻮﺭی ﻫﺴﺖ ﮐﻪ
ﺍﻭﻧﺠﺎ ﺑﻪ ﺩﻧﻴﺎ ﺍﻭﻣﺪﯾﺪ ﻭﻟﯽ ﺍﮔﻪ ﺍﯾﻦ ﮐﺸﻮﺭ ﺟﺰﻭ ﮐﺸﻮﺭﻫﺎﯾﯽ ﺑﺎﺷﻪ ﮐﻪ ﺗﻮ ﻟﻴﺴﺖ ﻻﺗﺎﺭی ﻧﻴﺴﺖ ﻫﻤﻮﻧﻄﻮﺭی ﮐﻪ
ﮔﻔﺘﻢ ﻣﺤﻞ ﺗﻮﻟﺪ ﻫﻤﺴﺮ ﻭ ﯾﺎ ﯾﮑﯽ ﺍﺯ ﻭﺍﻟﺪﯾﻨﺘﻮﻥ ﺍﮔﻪ ﺗﻮ ﻟﻴﺴﺖ ﻻﺗﺎﺭی ﺑﺎﺷﻪ ﺍﺳﻢ ﺍﻭﻥ ﮐﺸﻮﺭ ﺭﻭ ﺑﻨﻮﯾﺴﻴﺪ.
)ﺧﻴﻠﯽ ﻫﺎ ﺍﯾﻨﺠﺎی ﻓﺮﻡ ﺭﻭ ﺍﺷﺘﺒﺎﻩ ﭘﺮ ﻣﯽ ﮐﻨﻦ ﻭ ﺑﻌﺪ ﺍﺯ ﺑﺮﻧﺪﻩ ﺷﺪﻥ ﮐﻴﺴﺸﻮﻥ ﺑﺎﻁﻞ ﻣﯽ ﺷﻪ ﺍﮔﻪ ﻣﺤﻞ
ﺗﻮﻟﺪﺗﻮﻥ ﺍﯾﺮﺍﻥ ﻫﺴﺖ ﺣﺘﻤﺎ ﻭ ﺣﺘﻤﺎ ﺍﯾﻨﺠﺎ ﺑﺎﯾﺪ ﺍﯾﺮﺍﻥ ﺑﻨﻮﯾﺴﻴﺪ ﻧﻪ ﺟﺎی ﺩﯾﮕﻪ(
ENTRY PHOTOGRAPH(S) (7
ﻋﮑﺴﻬﺎ ﮐﻪ ﺗﻮ ﺍﯾﻦ ﻣﻮﺭﺩ ﯾﮏ ﻋﺎﻟﻤﻪ ﺣﺮﻑ ﺩﺍﺭﻡ ﺑﺮﺍﺗﻮﻥ
MAILING ADDRESS (8
–In Care Of, Address Line ,Address Line 2, City/Town
District/Country/Province/State, Postal Code/Zip Code, Country ,1
ﺁﺩﺭﺱ ﭘﺴﺘﯽ )ﺗﺎ ﺍﻭﻧﺠﺎﯾﯽ ﮐﻪ ﻣﻦ ﻣﻴﺪﻭﻧﻢ In Care Ofﯾﻌﻨﯽ ﺑﺮﺳﺪ ﺑﻪ ﺩﺳﺖ (...ﺁﺩﺭﺱ ﻻﯾﻦ 1ﻭ 2ﻓﻘﻂ ﺑﻪ
ﺧﺎﻁﺮ ﺍﯾﻨﻪ ﮐﻪ ﺍﮔﻪ ﺁﺩﺭﺳﺘﻮﻥ ﻁﻮﻻﻧﻴﻪ ﺗﻮ ﺳﻄﺮ ﺍﻭﻝ ﺟﺎ ﻧﺸﺪ ﺗﻮ ﺩﻭﻣﻴﺶ ﺑﻨﻮﯾﺴﻴﺪ .ﺁﺩﺭﺱ ،ﺷﻬﺮ /ﺷﻬﺮﺳﺘﺎﻥ،
ﻣﻨﻄﻘﻪ /ﻛﺸﻮﺭ /ﺍﺳﺘﺎﻥ /ﺍﻳﺎﻟﺖ ،ﻛﺪ ﭘﺴﺘﯽ /ﺯﻳﭗ ﻛﺪ ،ﻛﺸﻮﺭ
COUNTRY WHERE YOU LIVE TODAY (9
ﮐﺸﻮﺭی ﮐﻪ ﺍﻻﻥ ﺗﻮﺵ ﺯﻧﺪﮔﯽ ﻣﯽ ﮐﻨﻴﺪ
PHONE NUMBER (optional) (10
ﺷﻤﺎﺭﻩ ﺗﻠﻔﻦ )ﺍﺧﺘﻴﺎﺭی(
E-MAIL ADDRESS (optional)(11
ﺁﺩﺭﺱ ) EMAILﺍﺧﺘﻴﺎﺭی(
WHAT IS THE HIGHEST LEVEL OF EDUCATION YOU HAVE ACHIEVED, AS OF TODAY(12
You must indicate which one of the following represents your own highest level
ﺁﺧﺮﯾﻦ ﻣﺪﺭک ﺗﺤﺼﻴﻠﯽ ﮐﻪ ﺍﻣﺮﻭﺯ ﺩﺍﺭﯾﺪ .ﺷﻤﺎ ﺑﺎﯾﺴﺖ ﯾﮑﯽ ﺍﺯ ﺍﻋﺪﺍﺩ ﺯﯾﺮ ﺭﻭ ﺑﻨﻮﯾﺴﻴﺪ:
ﻭﺍﺣﺪ ﻓﻮﻕ ﻟﻴﺴﺎﻧﺲ ﮔﺬﺭﻭﻧﺪﻳﺪ(
Master degree (8ﻓﻮﻕ ﻟﻴﺴﺎﻧﺲ
,Some doctorate level courses (9ﺩﮐﺘﺮﺍﻱ ) ﻫﺮ ﺭﺷﺘﻪ ﺍﻱ( ﺑﺪﻭﻥ ﻣﺪﺭک )ﯾﻌﻨﯽ ﺗﻤﻮﻣﺶ ﻧﮑﺮﺩﯾﺪ ﻳﺎ ﻓﻘﻂ
ﭼﻨﺪ ﻭﺍﺣﺪ ﺩﮐﺘﺮﺍ ﮔﺬﺭﻭﻧﺪﻳﺪ(
.Doctorate degree (10ﻣﺪﺭک ﺩﮐﺘﺮﺍﻱ ﻫﺮ ﺭﺷﺘﻪ ﺍﻱ
Unmarried, Married, Divorced, Widowed, Legally Separated - MARITAL STATUS (13
ﻭﺿﻌﻴﺖ ﺗﺎﻫﻞ ﻣﺠﺮﺩ ،ﻣﺘﺎﻫﻞ ،ﻁﻼﻕ ﮔﺮﻓﺘﻪ ،ﺑﻴﻮﻩ ،ﺑﻪ ﺻﻮﺭﺕ ﻗﺎﻧﻮﻧﯽ ﺍﺯ ﻫﻢ ﺟﺪﺍ ﺷﺪﯾﺪ
Entries must include the name, date and place of birth of your :NUMBER OF CHILDREN (14
spouse and all natural children, as well as all legally-adopted children and stepchildren, who are
unmarried and under the age of 21 (do not include children who are already U.S. citizens or
Legal Permanent Residents), even if you are no longer legally married to the child’s parent, and
even if the spouse or child does not currently reside with you and/or will not immigrate with you.
.Note that married children and children 21 years or older are not eligible for the diversity visa
ﺗﻌﺪﺍﺩ ﻓﺮﺯﻧﺪ )ﺩﺭ ﻣﻮﺭﺩﺵ ﻗﺒﻼ ﺗﻮﺿﻴﺢ ﺩﺍﺩﯾﻢ(
Country of ,Name, Date of Birth, Gender, City/Town of Birth - SPOUSE INFORMATION (15
Failure to list your spouse will result in disqualification of the .Birth, Photograph
principal applicant and refusal of all visas in the case at the time of the visa
.interview
ﻣﺸﺨﺼﺎﺕ ﻫﻤﺴﺮ :ﻧﺎﻡ،ﺗﺎﺭﯾﺦ ﺗﻮﻟﺪ ،ﺟﻨﺴﻴﺖ ،ﺷﻬﺮ ﺗﻮﻟﺪ ،ﻛﺸﻮﺭﻣﺤﻞ ﺗﻮﻟﺪ ،ﻋﮑﺲ .ﺍﮔﻪ ﺍﯾﻦ ﻣﺸﺨﺼﺎﺕ ﺭﻭ ﻭﺍﺭﺩ
ﻧﮑﻨﻴﺪ ﮐﻴﺲ ﺷﻤﺎ ﭘﺬﯾﺮﻓﺘﻪ ﻧﻤﻴﺸﻪ.
Country of ,Name, Date of Birth, Gender, City/Town of Birth - CHILDREN INFORMATION (16
.Birth, Photograph: Include all children declared in question #14 above
ﻣﺸﺨﺼﺎﺕ ﻓﺮﺯﻧﺪﺍﻥ :ﻧﺎﻡ،ﺗﺎﺭﯾﺦ ﺗﻮﻟﺪ ،ﺟﻨﺴﻴﺖ ،ﺷﻬﺮ ﺗﻮﻟﺪ ،ﻛﺸﻮﺭﻣﺤﻞ ﺗﻮﻟﺪ ،ﻋﮑﺲ) .ﺩﺭ ﻣﻮﺭﺩﺵ ﻗﺒﻼ ﺗﻮﺿﻴﺢ
ﺩﺍﺩﯾﻢ ﻓﻘﻂ ﺍﯾﻦ ﻣﻄﻠﺐ ﺭﻭ ﻫﻢ ﺑﮕﻢ ﮐﻪ ﺍﮔﻪ ﺑﭽﺘﻮﻥ ﻗﻨﺪﺍﻗﯽ ﻫﺴﺖ ﺑﺎﯾﺪ ﻣﺸﺨﺼﺎﺕ ﺍﻭﻥ ﺭﻭ ﻫﻢ ﺑﻨﻮﯾﺴﻴﺪ(
ﻧﺤﻮﻩ ﻗﺮﻋﻪ ﮐﺸﯽ