N232184933

1. Type of Service } Normal X Urgent

2. Type of Travel Document } All Countries X Middle East

Countries
Emergency
Certificate
Identity
Certificate

3. Present Travel Document No. (If any) 4. NMPR No. (If any)

5. National Identity Card No. } 1 9 5 7 6 5 7 1 0 1 1 5

P E I R I S
6. Surname }
D E H I W A L A L I Y A N A G E W I M A
7. Other Names } L K A

3 4 4 / 5 M A H A W A T T E R O A D A
8. Permanent Address
} R A W W A L A E A S T P A N N I P I T I
Y A

8.1. District } C O L O M B O

9. Date of Birth } Date 0 5 Month 0 6 Year 1 9 5 7

10. Birth Certificate } No. 8 3 2 4 District C O L O M B O

11. Place of Birth } C A S T L E S T M A T E R N I T Y

12. Sex } Female X Male

13. Profession/ Occupation/ } U N E M P L O Y E D

14. Have you obtained Dual Citizenship in Sri Lanka? } Yes No X

If Yes, Dual Citizenship

(Please fill up fields 17 and 18 in the next page)

15. Mobile/ Phone No. (to be notified via SMS when passport is ready for } 0 7 2 0 2 5 7 4 2 0

16. E-mail Address } M A L K A G U N A S E K E R A @ G M A I L .

 Compulsory for Dual Citizenship Holders

17. Foreign Nationality

18. Foreign Passport No.