REPUBLIC OF THE PHILIPPINES DEPARTMENT OF FOREIGN AFFAIRS E-PASSPORT APPLICATION

PLEASE PROVIDE CORRECT INFORMATION AND DO NOT LEAVE SPACES BLANK LAST NAME / APELYIDO MIDDLE NAME / GITNANG PANGALAN DATE OF BIRTH / PETSA NG KAPANGANAKAN (Ex. 01 January 2010) Civil Status: Single Married FIRST NAME / PANGALAN (Jr. / II / III) PLACE OF BIRTH / POOK NG KAPANGANANAKAN
Post

/
Day Widow/er Month Annulled

/
Year

GENDER / KASARIAN:

MALE

FEMALE

Name of Wife / Husband: First Name Home Address: Present Occupation: Work Address: E-mail address: Name of Father: Maiden / Single Name of Mother: First Name Middle Name Last Name Middle Name Last Name

Citizenship: Tel. No.: Mobile No.:

Tel. No.: Citizenship: Citizenship: First Name Middle Name Last Name Purpose of Travel: R.A. 9225 (Dual Citizenship Law) Tour Study Yes No Seaman Work Business Other Yes No Migration

Citizenship Acquired By: Birth Election Naturalization Others

Are you a holder of a foreign passport? If Yes, from what country

Have you ever been issued a Philippine Passport If Yes, Latest Passport Number Date of Issue: Place of Issue: This serves as an Affidavit of Loss Lost Passport Number: Issued on: Date lost: Lost due to:

This serves as an Affidavit of Support and Consent to Travel (for Applicants below 18 years ONLY) Name of minor's travelling companion: Companion's Relationship: Address / Contact Number:

Issued by:

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: RECEIVED CANCELLED PASSPORT: FOR ADMINISTRATIVE USE ONLY: RECEIVED NEW PASSPORT:

Signing officer:

For details please visit www.philippinesusa.org

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