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THIS FORM IS Republic of the Philippines Received Cancelled Passport:

NOT FOR SALE PHILIPPINE EMBASSY, TOKYO                            


MACHINE READABLE PASSPORT (MRP) APPLICATION 
 SMC‐HMLS‐ Rev. January 2009 
 
 
FILL‐IN/ANSWER ALL ITEMS/QUESTIONS.  WRITE “NA” FOR NON‐APPLICABLE ITEMS.  PLEASE READ REQUIREMENTS AT THE BACK. 
 

SURNAME         
Apelyido                 
 

GIVEN NAME     
Pangalan (Jr./ II/ III etc.)                     Paste one 
4.5 cm. X 
  3.5 cm. 
colored 
MIDDLE NAME/MAIDEN NAME 
       Panggitnang Apelyido/          photo with 
ROYAL 
BLUE 
 

DATE OF BIRTH ___________________________________       SEX        □ Male           
 
 □ Female  background 

PLACE OF BIRTH __________________________________                                                               
                                                                                                                                                                                                                                                                                                                        

NAME OF FATHER_________________________________              Citizenship _____________________ 
                                                                                                                                                                                                                                                                            
NAME OF MOTHER_________________________________             Citizenship _____________________ 
 
 

Civil Status: □ Single           □Married         □Widowed          □Divorced          □Legally Separated          □Annulled  
If you are married, state the name of your spouse; if you are divorced/had your marriage annulled, or if you are widowed, state the name of 
your former spouse _____________________________________    Citizenship __________________________ 
 
ADDRESS IN JAPAN 
____________________________________________________________________________  Telephone No. ____________________ 
Postal Code              Prefecture                        City                               District/Town/Ward        Street                 Apartment Name/Building        Room/Floor Number     and/or Cellphone _________________ 
 
ADDRESS IN THE PHILIPPINES  
____________________________________________________________________________  Telephone No. ____________________ 
 Number                     Street                            Barangay                                      Town/City                                             Province/Region                                 ZIP Code            and/or Cellphone __________________
                                                                                                                                             

 
VISA CATEGORY/ STATUS OF RESIDENCE (Please select and check one) 
□Transit  (Stopover, Seaman)    □Specified (Designated Activities, Spouse or child of Japanese National,     □General   □Official/Diplomat 
(Cultural Activities, College Student,
                                                                             Spouse or Child of Permanent Resident, Long‐term Resident )                                        Pre‐college Student, Trainee, Dependent)                          (Official, During Mission ) 

□ Temporary Visitor   □Working (Professor, Artist, Religious Activities, Journalist, Investor/Business          □SOFA                          □ Others __________________ 


          ( Tourist/Temporary Visitor)        Manager, Legal/Accounting/Medical Services, Researcher ,Instructor, Engineer, Specialist        Status of Forces Agreement conditions 
                                                                    in Humanities, International Services, Intra‐company Transferee, Entertainer, Skilled Labor  
 

OCCUPATION _________________  WORK ADDRESS______________________________________ TELEPHONE No._______________ 
 

Are your parents married?                 □ Yes             □ No Have you been ever issued a         
 
Philippine Passport?                □ Yes        □ No 
Philippine citizenship acquired by:  If yes, please provide latest passport number ______________
□ Birth                         □ Election             □ Reacquisition (RA9225)             
□ Naturalization        □ Marriage  Place of Issue_________________ Date of Issue ___________ 
 
Natural Color of Eyes ________ Natural Color of Hair _______ 
Are you an employee of             
the Philippine Government?      □ Yes             □ No  Height (in meters) _________ Distinguishing Mark__________ 
 

Do you have a valid passport issued by other countries?  □ Yes   □ No      If yes, what country/ies? _____________________________
 
 

In the event of an emergency please provide contact details of parties to be notified. 
 

In the Philippines: Name _______________________ Address ______________________Telephone ____________ Relation ________
 
In Japan: Name _____________________ Address _______________________________ Telephone ____________ Relation ________
 
   

                            
FOR STRICT COMPLIANCE: (Embassy Personnel only) 
  I SOLEMNLY SWEAR, under pain   of perjury,  Remarks: 
  that the attached photograph are mine, and   
  that the statements made on this form are true  Attach 2 4.5 cm 
Processor: __________________ 
  and the attached documents are authentic  X 3.5 cm. 

  SO HELP ME GOD.   
colored photo   
with ROYAL 
        BLUE  Signing 
background 
  Officer: _____________________ 
 
▲Left Thumbmark                                                                                                ▲Right Thumbmark       
                                                                   

Received New Passport: 
 

►_______________________________________     
DO NOT  
                         Signature of Applicant  PERFORATE PHOTOS
 
 

Note: Application Form and copies of supporting documents submitted will be retained by the Embassy.  Application received and paid for, and later withdrawn or denied are not reimbursable.