J&H Immigration Services
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DV 応募詳細
DV応募（応募用紙）
DV当選者サポート
結婚でグリーンカード
About Us
アメリカ永住権・ビザ
Payment Center
Contact us
How to Apply DV Lottery
当社サービス内容
DV
-
2026 L
ottery
2024
年
10
月応募の
アメリカ抽選永住権
今年の応募は
終了
致しました。
来年のご応募を
よろしくお願いします↓
。。。。。。。。。。。。。。。。。。。。。。。。。。。。
J＆H申請
代行費
：
$45
/
1
名
*
Indicates required field
How did you hear about us? 情報は何処から？
*
Vivinavi びびなび
Internet search ネット検索
Rygakugram IG Miyukiさんの留学グラム
Weekly Lalala ラララ
Lighthouse ライトハウス
J＆H Repeater J＆Hリピーター様
Other その他
【DV
2026】Entry Form
↓ローマ字で
ご記入下さい
↓
1) Name-氏名 Firstは名前Lastは苗字となります。
*
First
Last
DV申請者ご本人様
1) Middle name if any ミドルネーム
*
2) Gender—性別
*
Male
Female
3) Birth Date Month (月)
*
January
February
March
April
May
June
July
August
September
October
November
December
3) Birth Date Day ( 生まれた日)
*
3) Birth Date Year（生まれた年）
*
西暦でお答えください 例）1978年
4) City where you were bornー出生地
*
県や府でなく ＝市、区、群、町、村で記載
5) Country where you were born—出生国
*
6) Country of eligibility for the DV programーDVプログラム対象国
*
日本人は「Japan」と記載
7) 応募用写真添付 Upload 240 KB or less photo
*
Max file size: 20MB
背景は白で無背景ーそれ以外は使用不可。
8) Mailing Addressー現住所
*
Line 1
Line 2
City
State
Zip Code
Country
9) Country where you live today 現在住んでいる国
*
10) Phone number ( optional ) (電話番号)
*
11) Email Eメールアドレス
*
12) Highest level of education you have achieved as of todayー最終学歴
*
1) Primary School only
2) Some high school, no diploma
3) High school diploma
4) Vocational School（専門学校／卒業専門学校）
5) Some university courses
6) University degree （大学卒業）
7) Some graduate-level courses
8) Master's degree
9) Some doctoral-level courses
10) Doctorate
13) Current marital statusー今現在の婚姻状況
*
1) Unmarried
2) Married and my spouse is NOT a US Citizen or US Lawful Permanent resident
3) Married and my spouse IS a US Citizen or US Lawful Permanent resident
4) Divorced
5) Widowed
6) Legally separated
Spouse's Information
if you're married:
配偶者の情報
(既婚者のみ)
14) Spouse's last name 配偶者のお名前
*
14) Spouse's first name 苗字
*
14) Birth Date month 生まれた月
*
Select one
January
February
March
April
May
June
July
August
September
October
November
December
14) Spouse's Birth Date Day 生まれた日
*
14) Spouse's Birth Date year 生まれた年
*
14) Spouse's Gender 性別
*
Select one
Male
Female
14) Spouse's City/Town of birth 生まれたー市区町村
*
14) Spouse's Country of birth 生まれた国
*
15) Spouse's Upload 240 KB or less photo for Lottery 配偶者様の応募用お写真を添付下さい
*
Max file size: 20MB
15) Spouse's Highest level of education you have achieved as of todayー最終学歴
*
1) Primary school
2) Some high school, no diploma
3) High school diploma
4) Vocational school
5) Some university courses
6) University degree
7) Some graduated level courses
8) Master's degree
9) Some doctoral level courses
10) Doctorate
Children's Information if any;
under 21 years of age
お子様の情報
：21
歳以下の全てのお子様を記入。
16) Number of children ( type 0 if none and go down to the payment section )
*
If none, type in NONE. – List the name, date of birth, gender, city/town of birth, and country of birth for all living unmarried children under 21 years of age, regardless of whether they are living with you or intend to accompany or follow to join you, should you immigrate to the United States. Submit individual photographs of each of your children using the same technical specifications as your own photograph. Be sure to include: -all living natural children; -all living children legally adopted by you; and, -all living step-children who are unmarried and under the age of 21 on the date of your electronic entry, even if you are no longer legally married to the child’s parent, and even if the child does not currently reside with you and/or will not immigrate with you.
17) Children's #1 Name お子様のFirst名前 Last苗字
*
First
Last
[object Object]
17) #1 Children's Date of birth 誕生日
*
Month/Day/Year
17) #1 Children's Gender
*
Select one
Male
Female
17) #1 Children's City/town of birth 生まれた市区町村
*
17) #1 Children's Country of birth 生まれた国
*
17) #1 Children's Upload photo—①お子様写真添付
*
Max file size: 20MB
18) #2 Children's Name ２番目のお子様
*
First
Last
[object Object]
18) #2 Children's Date of birth
*
Month/Day/Year
18) #2 Children's Gender
*
Select one
Male
Female
18) #2 Children's City/town of birth
*
18) #2 Children's Country of birth
*
18) #2 Children's Upload photo—応募用写真
*
Max file size: 20MB
19) #3 Children's name ３番目のお子様
*
First
Last
[object Object]
19) #3 Chid's Date of birth
*
Month/Day/Year
19) #3 Children's Gender
*
Select one
Male
Female
19) #3 Children's City/town of birth
*
19) #3 Children's Country of birth
*
19) #3 Children's Upload photo—応募用写真
*
Max file size: 20MB
19) #4 Children's name
*
First
Last
[object Object]
19) #4 Children's Gender
*
Select one
Male
Female
19) #4 Children's City/town of birth
*
19) #4 Children's Country of birth
*
19) #4 Children's Upload photo—応募用写真
*
Max file size: 20MB
20) Payment info:
お支払い情報
$
45
/1
名
お申込み人数をお選び下さい。
*
１名様 $45 申請者のみ
２名様 $45x2 ご夫妻様で応募
Credit or Debit Card Number
*
Amex, Discover, Master Card, and Visa. JCB not accepted.
Name on Credit Card
*
Expiration Date
*
Security Number
*
Billing Zip Code Credit card
*
【同意書】
当社J＆Hイミグレーションサービスが
DV代行費を支払う事に
同意致します。
..........................................................
同意して↓下の「同意」ボックスと
一番下の「承諾ボタン」を押したら
お申し込みが全て完了です！
＊チェックボックスをクリックしない場合、
お申し込みは当社へ提出されませんのでご注意ください。
Check box 同意ボックス
*
By checking the box, I agree to allow J&H Immigration Services to charge my credit card.
Comment お問い合わせ・ご質問
*
Submit 承諾ボタン
ホーム
業務内容
DV 応募詳細
DV応募（応募用紙）
DV当選者サポート
結婚でグリーンカード
About Us
アメリカ永住権・ビザ
Payment Center
Contact us
How to Apply DV Lottery
当社サービス内容