23.10.2016.

ElectronicDiversityVisaLottery
U.S.DepartmentofState

(http://www.state.gov)

BureauofConsularAffairs
eDVAES:12.02.00
Help(Help.aspx)

ElectronicDiversityVisaEntryForm
OMBControlNumber:14050153
Form:DS5501
Expires:08/31/2019
EstimatedBurden:30minutes

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PartOneEntrantInformation
1.Name
a.Last/FamilyName
Mihajlovic
b.FirstName
Dusan
c.MiddleName

2.Gender
Male

3.BirthDate
May26,1989

4.CityWhereYouWereBorn
Vranje

5.CountryWhereYouWereBorn
Serbia

6.CountryofEligibilityfortheDVProgram
Serbia

7.EntrantPhotograph
(Photographreceived)

8.MailingAddress

a.InCareOf(optional)

b.AddressLine1
HadziTomina82
c.AddressLine2(optional)

d.City/Town
Vranje
e.District/County/Province/State
SouthSerbia/Serbia
f.PostalCode/ZipCode
17501

https://www.dvlottery.state.gov/application.aspx

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23.10.2016.

ElectronicDiversityVisaLottery

g.Country
Serbia

9.CountryWhereYouLiveToday
Serbia

10.PhoneNumber
+381603581000

11.EmailAddress
dusan.mvr@gmail.com
(NOTE:Thisemailaddresswillbeusedtoprovideyouwithadditionalinformationifyouareselected.)

12.Whatisthehighestlevelofeducationyouhaveachieved,asoftoday?
UniversityDegree
Youmusthaveaminimumofahighschooldiplomareflectingthecompletionofafullcourseofstudy(vocationschoolsorequivalencydegreesarenot
acceptable)orbeaskilledworkerinanoccupationthatrequiresatleasttwoyearsoftrainingorexperiencetoqualify(visithttp://www.onetonline.org/
(http://www.onetonline.org/)toseeifyouroccupationqualifies)foraDiversityVisa.

13.Whatisyourcurrentmaritalstatus?
Unmarried
Legalseparationisanarrangementwhenacoupleremainmarriedbutliveapart,followingacourtorder.Ifyouandyourspousearelegallyseparated,
yourspousewillnotbeabletoimmigratewithyouthroughtheDiversityVisaprogramhowever,youmustincludeyourspouseevenifyouplantobe
divorcedbeforeyouapplyfortheDiversityVisa.Failuretolistyoureligiblespouseisgroundsfordisqualification.IfyourspouseisaU.S.citizenorLawful
PermanentResident,donotlisthim/herinyourentry.

14.NumberofChildren
0
Childrenincludeallbiologicalchildren,legallyadoptedchildren,andstepchildrenwhoareunmarriedandundertheageof21onthedateyousubmityour
entry.Youmustincludealleligiblechildren,eveniftheydonotlivewithyouoriftheydonotintendtoapplyforaDiversityVisaasyourderivative.Failureto
listalleligiblechildrenisgroundsfordisqualification.IfyourchildisaU.S.citizenorLawfulPermanentResident,donotlisthim/herinyourentry.

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PAPERWORKREDUCTIONACT:Publicreportingburdenforthiscollectionofinformationisestimatedtoaverage30minutesperresponse,includingtimerequiredforsearchingexistingdata
sources,gatheringthenecessarydocumentation,providingtheinformationand/ordocumentsrequired,andreviewingthefinalcollection.Youdonothavetosupplythisinformationunlessthis
collectiondisplaysacurrentlyvalidOMBcontrolnumber.Ifyouhavecommentsontheaccuracyofthisburdenestimateand/orrecommendationsforreducingit,pleasesendthemto:
PRA_BurdenComments@state.gov.
CONFIDENTIALITYSTATEMENT:TheinformationaskedforonthisformisrequestedpursuanttoSection222oftheImmigrationandNationalityAct.INASection222(f)providesthatvisa
issuanceandrefusalrecordsshallbeconsideredconfidentialandshallbeusedonlyfortheformulation,amendment,administration,orenforcementoftheimmigration,nationality,andother
lawsoftheUnitedStates.Certifiedcopiesofvisarecordsmaybemadeavailabletoacourtwhichcertifiesthattheinformationcontainedinsuchrecordsisneededinacasependingbeforethe
court.

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ThissiteismanagedbytheBureauofConsularAffairs,U.S.DepartmentofState.ExternallinkstootherInternetsitesshouldnotbeconstruedasanendorsementoftheviewscontainedtherein.

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