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ELECTRONIC DIVERSITY VISA ENTRY FORM OMB Control Number: 1405-0153
Form: DS-5501
Expires: 05/31/2010
Estimated Burden: 30 minutes
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Part One - Entrant Information

1. Name

a. Last/Family Name
Kantsara
b. First Name
Valeriy
c. Middle Name
Dmitrievich

2. Birth Date

Tuesday, March 17, 1959

3. Gender

Male

4. City Where You Were Born

Andreevka

5. Country Where You Were Born

Ukraine

6. Country of Eligibility for the DV Program

Ukraine

7. Entrant Photograph

(Photograph received)

8. Mailing Address

8a. In Care Of Alchevsk
8b. Address Line 1 Alchevsk
8c. Address Line 2 Alchevsk
8d. City/Town Alchevsk
8e. District/County/Province/State Prospect Metallurgists, 48, Luhansk region
8f. Postal Code/Zip Code 94206
8g. Country Ukraine
(NOTE: This is the address that will be used to notify you if you are selected.)

9. Country Where You Live Today

Ukraine

10. Phone Number

0380644246693

11. E-mail Address

d20088002@gmail.ru

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

University Degree

You must have a minimum of a high school diploma reflecting the completion of a full course of study (vocation schools or equivalency degrees are not acceptable) or be a skilled worker in an occupation that requires at least two years of training or experience to qualify (visit http://online.onetcenter.org/ {this link will open in a new window} to see if your occupation qualifies) for a Diversity Visa.

13. What is your current marital status?

Married

Legal separation means that a court has formally declared that you and your spouse are legally separated. Legal separation means that your spouse would not be eligible to immigrate as your derivative.

14. Number of Children

1

Children include all biological children, legally adopted children, and stepchildren who are unmarried and under the age of 21 on the date that you submit your entry. Failure to include all children or inclusion of children who are not your biological children, legally adopted children, and stepchildren (regardless of whether they live with you and/or intend to apply for a visa as your derivative) is grounds for disqualification of the entire entry.

Legal Permanent Residents (LPR) and American Citizens should not be included.

Part Two - Derivatives

13. Spouse Name

a. Last/Family Name
Kantsara
b. First Name
Zoya
c. Middle Name
Ivanovna

13d. Birth Date

Tuesday, March 01, 1960

13e. Gender

Female

13f. City Where Spouse Was Born

Alchevsk

13g. Country Where Spouse Was Born

Ukraine

13h. Spouse Photograph

(Photograph received)

14. Child #1 Name

a. Last/Family Name
Kantsara
b. First Name
Valeriya
c. Middle Name
Valerievna

14d. Birth Date

Thursday, June 03, 1993

14e. Gender

Female

14f. City Where Child Was Born

Alchevsk

14g. Country Where Child Was Born

Ukraine

14h. Child Photograph

(Photograph received)

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