FOR OFFICIAL USE ONLY

Registered in GBA / RNI Yes No

First Time Request? Yes No

Current Passport Handed in Valid returned Missing

Will be handed in Invalid returned

Current Dutch ID Card / Handed in Valid returned Missing

Emergency Passport /
Laissez-passer Will be handed in Invalid returned

Travel Document Application Form

The fee for the document must be paid when submitting the application.
Date of application 10-06-2023
Surname(s) Jalloh
Given name(s) Yaghouba
Phone number +33783057630
Email address m_2jalloh@yahoo.com
Decision via email Yes
Contact address 25 rue du roussillon
69330
Meyzieu, Lyon
France Placeholder Photo Card
For official use only

New Travel Documents and Identity Personal Details

Country of application France

Applying for document(s) Passport
Gender Male
Height in cm 182
Dutch citizen service number (BSN) 389103135
Date of birth 03-09-2008
Place of birth Rotterdam
Country of birth Netherlands
Marital status Never married

Front Office Back Office Back Office

Initials employee Initials employee Initials coordinator

1 992374
Parent(s) / Legal Guardian(s) Personal Details

Who will be present at the Both of my parents

appointment?

Information parent / legal guardian that will come to the appointment

Given name(s) Mohamed
Surname(s) Jalloh
Information parent / legal guardian that will come to the appointment
Given name(s) Mariama Daka
Surname(s) Diallo

Current Address Personal Details

Address 25 rue du roussillon

Postal Code 69330
City Meyzieu
State / province Lyon
Country France
Is this your current country of Yes
residence?
Since when do you live in France? 01-08-2014
Do you have a residence permit for or No, I do not have either
a citizenship of France?

Previous Residency in the Netherlands Personal Details

Did you ever live in the Netherlands, in Yes: 2014

what municipality?
Did you deregister? Yes
What year did you leave the 2014
Netherlands?

Dutch Nationality Dutch Nationality

Specify how you obtained the Dutch Birth

nationality

2 992374
Current Dutch Documents Dutch Nationality

Are there valid Dutch travel documents Yes

on your name?
Any of these documents stolen / lost / No
at a different location?

Passport Dutch Nationality

Document number NM9F7HD55

Date of issue 25-07-2018
Authority Minister van nederlandse zaken

Other Nationalities Other Nationalities

Do you hold any other nationalities No

besides the Dutch nationality?

3 992374
Signature
I, the undersigned, hereby explicitly declare that the information I have provided above is truthful and that the
photo submitted bears a true, current likeness to me. I also hereby explicitly declare that I have not lost my Dutch
nationality by voluntarily acquiring another nationality, or in any other way that I am aware of, and that to the best
of my knowledge I hold Dutch nationality.

By signing this form I agree that my personal data may be shared with other government agencies in order to
confirm my nationality and identity for the purposes of issuing a Dutch travel document.

I agree to any correspondence relating to this application being sent to the email address I provided on the first
page of the application form.

I am aware that the fees paid are non refundable.

Declaration of consent for the decision on your application to be sent by email

If your passport application is not processed or is rejected, you will receive a decision in writing, to which you can
lodge an objection. If you wish to receive the decision by email, you need to make this known. You should use an
email address which you access on a regular basis.

I agree for the decision on my passport application to be sent to the email address as provided by me.

The Ministry of Foreign Affairs accepts no responsibility for any email messages that fail to reach you or are
delayed. The Ministry of Foreign Affairs cannot guarantee the reliability of sending or receiving messages by email,
or the confidentiality and integrity of email correspondence sent over the internet.

Place and date Signature

4 992374
Signatures Parent(s) / Legal Guardian(s)
If this application relates to a minor, all those with parental responsibility/authority over this minor must sign this
form to declare that they give permission for the application to be processed. If (one of) the parents or legal
guardian(s) is unable to sign this form, a separate duly signed parental consent form must be submitted in addition
to the application.

Place and date

Jalloh Mohamed
Parent/Legal Guardian(1) Signature

Diallo Mariama Daka

Parent/Legal Guardian(2) Signature

5 992374
Privacy declaration: Travel document or Dutch ID-card application
The Ministry of Foreign Affairs handles the personal data in your travel document application with the utmost care.

Personal data is information that can be traced to an individual, such as names, postal addresses and email
addresses. Fingerprints are also personal data. Personal data is protected under the General Data Protection
Regulation(GDPR).

Processing of personal data

The Ministry of Foreign Affairs processes personal data in order to carry out its public tasks. The ministry is
responsible for ensuring that your personal data is processed in accordance with the GDPR.

Data sharing
When carrying out tasks under the Passport Act and the Passport Regulations (Embassies and Consulates) 2001,
including article 85 of the latter, the Ministry of Foreign Affairs may be required to share information, including your
personal data, with other organisations

For example, the Ministry of Foreign Affairs may share data with the manufacturer of your passport or identity
card, the National Office for Identity Data or investigators. This is necessary for your application to be processed. It
may also be necessary for the purpose of examining travel document irregularities or in the context of a criminal
investigation.

It is possible that your data may be requested by and passed on to local authorities, for instance in connection with
a subsequent application or registration with the municipality. In addition, commercial postal companies are used
to transfer documents and files relating to travel document applications.

Protecting personal data

The Ministry of Foreign Affairs will ensure that your personal data is appropriately protected.

Retention period for personal data

The Ministry of Foreign Affairs will retain your personal data for no longer than is necessary for the purpose
concerned, and in accordance with the Passport Act and the Passport Regulations (Embassies and Consulates)
2001.

Your privacy rights

You can submit a request in any of the following situations:

If you wish to know which personal data of yours the ministry is processing
If you wish to amend your personal data
If you wish to have your personal data deleted
If you wish us to limit the processing of your personal data

6 992374