e-passport application form - Philippine Consulate General in Los

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e-passport application form - Philippine Consulate General in Los Powered By Docstoc
					                                                                              REPUBLIC OF THE PHILIPPINES
                                                                           DEPARTMENT OF FOREIGN AFFAIRS

                                                                                                   Post
                                                                                 E-PASSPORT APPLICATION
                  PLEASE PROVIDE CORRECT INFORMATION AND DO NOT LEAVE SPACES BLANK
LAST NAME / APELYIDO                                                      FIRST NAME / PANGALAN (Jr. / II / III)


MIDDLE NAME / GITNANG PANGALAN                                            PLACE OF BIRTH / POOK NG KAPANGANANAKAN

DATE OF BIRTH / PETSA NG KAPANGANAKAN                                                                       GENDER / KASARIAN:                  MALE         FEMALE
(Ex. 01 January 2010)                                             /                  /
                                                          Day          Month             Year
Civil Status:      Single          Married           Widow/er         Annulled

Name of Wife / Husband:                                                                                                           Citizenship:
                                        First Name                        Middle Name                          Last Name
Home Address:                                                                                                                       Tel. No.:

Present Occupation:                                                                                                                 Mobile No.:

Work Address:

E-mail address:                                                                                                                     Tel. No.:

Name of Father:                                                                                                                   Citizenship:

Maiden / Single            First Name                        Middle Name                        Last Name
Name of Mother:                                                                                                                   Citizenship:

                                First Name                            Middle Name                         Last Name

                Citizenship Acquired By:                                                                  Purpose of Travel:
                   Birth                Naturalization          R.A. 9225 (Dual Citizenship Law)             Tour          Seaman      Business           Migration

                   Election             Others                                                               Study         Work        Other

                  Are you a holder of a foreign passport?                Yes        No                    Have you ever been issued a Philippine Passport             Yes        No

                   If Yes, from what country                                                              If Yes, Latest Passport Number


                                                                                                          Date of Issue:                         Place of Issue:

                       This serves as an Affidavit of Support and Consent to Travel                                        This serves as an Affidavit of Loss
                                   (for Applicants below 18 years ONLY)
                                                                                                          Lost Passport Number:
                   Name of minor's travelling
                   companion:                                                                             Issued on:                       Issued by:
                   Companion's Relationship:                                                              Date lost:

                                                                                                          Lost due to:
                   Address / Contact Number:



                                                      Signature of Parent or Legal Guardian                                                  Signature of Applicant


I SOLEMLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided in this application is true and correct. 3) The supporting documents attached are authentic.
4) I have not been issued a passport under any other name. 5) I am aware that under the law, I am allowed to hold one Philippine passport at any given time. 6) I am aware
that making false statements in passport application furnishing falsified or forged documents is punishable by law.


                                                                                                                                             Signature of Applicant
Remarks:

FOR STRICT COMPLIANCE: Please print name and affix initials.
Processor:                                                   Encoder:                                                                        Signing officer:

RECEIVED CANCELLED PASSPORT:                                                                RECEIVED NEW PASSPORT:

FOR ADMINISTRATIVE USE ONLY:

                                                                                                                                           For details please visit www.philippinesusa.org

				
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