Passport Application (IM.42 – Pin.

1/97) Translation

A. Personal Particulars
1. Full name (as in your Malaysian IC)
2. Other Names (if any)
3. (i) ID number
(ii) Birth certificate No.
4. Date of Birth (DD/MM/YYY)
5. State you were born (if out of Malaysia please provide country)
6. Sex
7. Current address in the U.S.
8. Height (in centimeters)
9. Marital Status - single, married, divorce

B. Replacement of Passport
10. Current passport no.

C. For lost passport only

11. Lost passport no.

D. To include child's photo in the passport

12. Fill out section A, D, and E, 2 current photos, current passport no.

E. Agreement
13. (a) I am applying for a passport to be issue to me/child as in section A
(b) I declare that I/Child have/don’t have a passport no:
(c) I parent/legal guardian requesting to insert recent photo of my child as
in section D.
(d) I declare all information provided in this application is true. I
understand it is against the law to provide false information, if find guilty, I
can be fine for no less than RM10,000 and not more than RM50,000 or
Jail no less than one year and not more than five years or both.
Date: Applicant Signature

For applicant under 18 yrs old, please include parent/legal guardian

information:
Name:
ID No. Parent/legal guardian signature