NIGERIA IMMIGRATIONSERVICE

E-PASSPORT APPLICATION FORM

APPLICANTS’ VERIFICATION FORM

TITLE: MR/MRS/MISS/DOCTOR 32 PAGES 5 YEARS ( )64 PAGES 5YRS ( ) 10YRS ( )

National Identity Number………………………………………………………………………………………………………………………………….

Surname ………………………………………………………………………………………………………………………..…………………………………..

First Name……………………………………………………………………………………………………………………………………………………........

Middle Name……………………………………………………………………………………………………………………………………………………..

Sex ________________Date of Birth ___________________________Place of Birth ___________________________

House Address ___________________________________________________________________________________

Line 2 ____________________________________________ City ___________________________________________

L.G.A _________________________________________ State _____________________________________________

State of Origin _________________________ Local Govt. ________________ Home Town _______________________

Nationality ____________________________ Occupation ________________________________________________

Maiden Name (Married Women Only) ________________________Marital Status ______________________________

Date of Marriage (for married women only) _______________________________________________________________

Mobile Phone______________________________ Email Address___________________________________________

Have you ever obtained e-Passport? Yes No

Date of Issue ____________________ Expiry Date _____________________ E-passport No_______________________

Special features___________________________________________________________________________________

Next of kin name_______________________________________ Relationship with next of kin ___________________

Next of kin address ________________________________________________________________________________

City _______________________________ L.G.A __________________________ State _________________________

Mobile Phone of Next of Kin ____________________________________________

This is to acknowledge that any false Declaration on this form may lead to withdrawal of Passport and prosecution of application under
Section 10 Immigration Act 2015.

Applicant Signature……………………………………………………………………………….. Date ________________________________________

OFFICIAL USE ONLY:

Name of Verification Officer………………………………………………….. Rank………………………………………………………………………………………………………..

Signature of Verification Officer…………………………………………………………… Date……………………………………………………………………………………

Name of Counter-Signing Officer (Approving)………………………………………………. Rank……………………………………………………………………………

Signature of Counter-signing Officer (Approving)……………………………………………………… Date………………………………………………………………………