ELECTRONIC DIVERSITY VISA ENTRY FORM Approved OMB 1405-0153
Platne do: Expires: 03/31/2004
Estimated Burden: 30 minutes
Prihlaska trva vyplnit zhruba 30 minut

Part One - Applicant Information  
Prva cast - Informacie o Ziadatelovi

1. Name - Meno

1a. Last/Family Name
Priezvisko 		1b. First Name
Meno 		1c. Middle Name
"stredne" Meno
No Last/Family Name
 dajte fajku ak nemate priezvisko
No First Name
dajte fajku ak nemate meno
No Middle Name
dajte fajku ak nemate 
"stredne" meno.  
Ak nemate tretie meno v 
pase, na rodnom liste,
alebo v obcianskom, 
nepsite ho.

2. Birth Date- datum narodenia

Den
Mesiac
Rok

3. Gender  - pohlavie

Male muz
Female zena

4. City/Town of Birth- Mesto/Dedina Narodenia

Birth City/Town Unknown
Ak neviete kde ste sa narodili, dajte fajku

5. Country of Birth - stat narodenia

6. Applicant Photograph  - vasa fotka

Rozmer fotky a vsetky info ohladom fotiek je uz prelozene na www.foltan.com/gc .  Predtym ako zacnete vypisovat prihlasku, kontrolujte si fotku na:  http://www.dvlottery.state.gov/photo.php  

A digital photograph (image) must be submitted for each person listed on an Application. This image must be in the Joint Photographic Experts Group (JPEG) File Interchange Format (JFIF) format. If the image is created by using a digital camera, it must have a resolution of 320 by 240 pixels, with either 24-bits of color, 8-bits of color or 8-bits of gray. If the image is created by scanning a photographic print the original print must have been 2" by 2" (50mm x 50mm), and the scan must be performed at a resolution of 150 dots per inch (dpi); the image must have a resolution of 300 by 300 pixels, with either 24-bits of color, 8-bits of color or 8-bits of gray. The image can not exceed 62,500 bytes (62.5KB) in size. Monochrome images (2-bits of color) will not be accepted. Please refer to the DV2005 Instructions for the pose and background requirements for all photographs.
Photograph File Name
Meno suboru s vaskou fotkou:  (kliknite na "browse" a najdite si ju na vasom pocitaci)
If you know the location in the computer and the name of the file which is storing the photograph, enter it in the box to the left of the 'Browse' button. If you are not sure of the location in the computer or the name of the file, clicking the 'Browse' button will allow you to look for and choose the file which is storing the photograph, and after you choose the file its name will appear in the box on the left.

7. Mailing Address - Vasa adresa

7a. In Care Of - Ak nemate na schranke vase meno, mozete sem napisat meno vlastnika bytu, aby postar vedel do ktorej schranky ma vas vyherny list dat.  Ak mate na schranke meno, nemusite sem nic pisat. 
7b. Address 1 Vasa adresa:
7c. Address 2 Vasa adresa: (ak potrebujete viac miesta)
7d. City/Town Mesto/dedina:
7e. District/County/Province/State Okres:
7f. Postal Code/Zip Code PSC:
No Postal/Zip Code
Dajte fajku ak nemate Postove Smerovacie Cislo
7g. Country Stat:
(NOTE: This is the address that will be used to notify you if you are selected.) Na tuto adresu vam pride vyherny list - ak vyhrate.

8. Phone Number - Telefonne Cislo

Optional - mozete dat ak chcete

9. E-mail Address - Email adresa

Optional - mozete dat ak chcete

10. Country of Eligibility  - Krajna cez ktoru ziadate o zaradenie do loterie.  

Are you claiming eligibility based on your Birth Country? Yes No
Ziadate o prihlasenie do loterie cez stat v ktorom ste sa narodili?  Ak ste sa narodili v CSSR, dajte "yes".   99% ludi na slovensku da "yes".   (nezalezi na tom kde teraz Byvate, zalezi iba na tom kde ste sa narodili)

If not, you must enter the country from which you are claiming eligibility. Ked ste dali "no" v predchadajucej otazke, zvolte krajnu cez ktoru ziadate. Na stranke je o tomto probleme pisane: www.foltan.com/gc  

11. Are You Married? Ste zenaty?

12. Number of Children  - Kolko mate deti?

Number of Children Pocet Deti:

(Unmarried and under 21 years of age) (pocitajte iba slobodne deti ktore este nemali 21 rokov)


Pokracuj
Vsetko Vymaz
DS-5501

PAPERWORK REDUCTION ACT  - Nic zaujimave a potrebne, iba nejake zakony a pod.

*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/RPS/DIR)
Washington, D.C. 20520.

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