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DV
CREDIT CARD PAYMENT FORM
- We must receive
all COMPLETE applications
by 5:00pm
EST, Friday, November 23,
2007, to ensure
that they meet the deadline
for submission.
- Once we receive
a credit card payment, we
will begin on your case immediately.
We cannot issue refunds.
Therefore, PLEASE
ENSURE ALL APPLICANTS' ELIGIBILITY
BEFORE FAXING PAYMENT FORM.
Payment forms
must be complete before we can
begin processing.
| Card
Holder Name |
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| Country/City/Date
of Birth |
|
| Alternate
Country of Nativity
(if any): |
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| Credit
Card Type, Number, Expiration
Date |
|
| Billing
Address for Card, including
Zip Code |
|
| Billing
telephone number |
|
| Tele.
Number where applicant
can be reached |
|
| Applicant's
complete address |
|
| Please
specify if
you want to use our
contact address or yours
for
correspondence from Consular
Center should you win the
lottery |
|
| Applicant's
Email address |
|
Fees
| Prior
to Oct 20, 2007,
US$75 for principal applicant |
|
| Prior
to Oct 20, 2007,
US$25 each for spouse/child
over 18 (if you would like
separate entry for spouse/children
over 18) |
|
| Between
Oct 20 and prior to Nov
16, 2007, US$100 for
principal applicant |
|
| Between
Oct 20 and prior to Nov
16, 2006, $50 each for
spouse/children over 18
((if you would like separate
entry for spouse/children
over 18) |
|
| On
or after Nov 16, 2007,
$135 for principal applicant
|
|
| On
or after Nov 16, 2007,
$75 for each for spouse/children
over 18 ((if you would like
separate entry for spouse/children
over 18) |
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| Total
Amount (US$) |
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I understand
that Kirberger PC will begin
work on my lottery application
immediately upon receipt of
this form, and that therefore,
refunds cannot be issued once
this form has been received
by this office. Please write
"yes" to indicate
that you understand and agree
to this (REQUIRED): __________
Credit Card
Holder's Signature (required):________________________________________
Once we receive
your payment information, we
will email confirmation and
further instructions.
PLEASE DO
NOT SEND YOUR CREDIT CARD NUMBER
VIA EMAIL. OUR SERVER
IS NOT SECURE FOR THIS PURPOSE.
PLEASE PRINT AND FAX THIS
FORM TO OUR OFFICE.
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