OMB Control Number: 1405-0153

Form: DS-5501
ELECTRONIC DIVERSITY VISA ENTRY FORM Expires: 05/31/2010
Estimated Burden: 30 minutes

If you need to go back and make a correction, DO NOT use the back button on your browser. Go Back to Part 1
Instead use the appropriate button here or below:

Part One - Entrant Information

1. Name
a. Last/Family Name b. First Name c. Middle Name
KHAN MD. KABIR
2. Birth Date
Tuesday, January 01, 1985
3. Gender
Male
4. City Where You Were Born
COMILLA
5. Country Where You Were Born
Bangladesh
6. Country of Eligibility for the DV Program
Bangladesh
7. Entrant Photograph
(Photograph received)
8. Mailing Address
8a. In Care Of MD. ASALAT KHAN
8b. Address Line 1 VILLAGE-PURNAMATI
8c. Address Line 2 POST OFFICE-PURNAMATI
8d. City/Town P.S: BURICHONG
8e. District/County/Province/State DISTRICT-COMILLA
 8f. Postal Code/Zip Code 3520
8g. Country Bangladesh
(NOTE: This is the address that will be used to notify you if you are selected.)
9. Country Where You Live Today
Bangladesh
10. Phone Number
01913160334, 01714397705
11. E-mail Address
Electronic delivery of DV correspondence may be offered in the near future. Please enter an email address in the box
below if you would prefer to receive correspondence electronically.
salinakabir2007@gmail.com
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?
Unmarried

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
0

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.
Cancel Entry Submit Entry Go Back to Part 1

Please print this page for your personal records. You will need to use your browser's print button for this.

PAPERWORK REDUCTION ACT

 *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/ISS/DIR)
Washington, D.C. 20520.
 OMB Control Number: 1405-0153
Form: DS-5501
ELECTRONIC DIVERSITY VISA ENTRY FORM Expires: 05/31/2010
Estimated Burden: 30 minutes

Submission Confirmation: Entry Received

Success!

Your entry for the 2010 Diversity Visa Lottery Program Lottery Entry Form was received on Thursday, October 30,
2008 at 2:52:27 PM EDT. Please do not close this window until you have printed this confirmation page or made a
record of your Confirmation Number.

Entrant Name: KHAN, MD. KABIR

Confirmation Number: 20101AZEWXP6O2JR

Thank you for your entry for the 2010 Diversity Visa Lottery.

Please either print this page or make a record of the confirmation number before closing this window. You
will not be able to retrieve this number after you close this window.
You must retain your confirmation number in order to check your entry status using the internet. You may check
back on this site at anytime between July 1, 2009 and June 30, 2010 to determine whether your entry was selected
for further processing in the 2010 DV Lottery. You will be required to enter your confirmation number in
combination with other personal information in order to check on your entry status.
Selectees will also receive a letter through their country's postal service notifying them of their selection. Entrants
who are not selected for further processing will not receive any type of notification through mail.
Do not submit additional Entry Forms with this person as the Primary Entrant! Multiple entries will
disqualify the entrant from participation in the Lottery.
PAPERWORK REDUCTION ACT
*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/ISS/DIR)
Washington, D.C. 20520.