Important Reminders

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Your appointment is on Thu, Nov 24, 2011 at 10:00 am. Please be at DFA Aseana by 09:30 am.

Please make sure you have prepared all the requirements. You can view the list at www.passport.com.ph

Please make sure to photocopy all of your requirements. Applicants without a complete set of photocopies will not be entertained.

For your NSO certificate requirements, you may call (02) 737-1111. Nationwide delivery within 3-4 days.

You may have your passport delivered for extra convenience. Please prepare extra P120 for the delivery fee.

Please print this page and the application form on LONG BOND PAPER. Applicants without the printed application form will not be allowed entry at the DFA. Please complete the application form before going to the DFA.

For questions or concerns, you may email info@passport.com.ph. Thank you for using the DFA Passport Appointment System.

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

Thu, Nov 24, 2011 10:00 NOT PLEASE PROVIDE CORRECT INFORMATION AND DOam LEAVE SPACES BLANK
REPUBLIC OF THE AND DO NOT PLEASE PROVIDE CORRECT INFORMATIONPHILIPPINES LEAVE SPACES BLANK DEPARTMENT OF FOREIGN AFFAIRS MANILA LAST NAME / APELYIDO FIRST GRACE DE ASIS BABY NAME / PANGALAN (Jr. / II / III) E-PASSPORT APPLICATION LAST NAME / APELYIDO FIRST NAME / PANGALAN (Jr. / II / III) PLEASE PROVIDE CORRECT INFORMATION AND DO NOT LEAVE SPACES POOK NG KAPANGANAKAN MIDDLE NAME / GITNANG PANGALAN PLACE OF RIZAL BAGTAS NAVOTASBIRTH / BLANK MIDDLE NAME / GITNANG PANGALAN DATE15, 1975 (Ex. Day/Month/Year) LAST NAME / APELYIDO JAN OF BIRTH DATE OF BIRTH (Ex. Day/Month/Year) Civil Status: Single PLACE OF BIRTH / POOK NG KAPANGANAKAN GENDER FIRST NAME / PANGALAN (Jr. / II / III) FEMALE / KASARIAN Married GENDER Legally Separated / KASARIAN Widow/er Annulled

Civil Single X Married Widow/er Legally Separated Annulled Name of Wife / Husband: Status: Citizenship: MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN Name of Wife / Husband: PUROK 19 SITIO SAN LORENZO RUIZ BRGY. SAN ROQUE, ANTIPOLO CITY Citizenship: 09075490076 Complete Address: Tel. No: RIZAL Complete Address: Present Occupation: Tel. No: Mobile No: 09075490076 NONE Present Occupation: Day/Month/Year) DATE OF BIRTH (Ex. NONE GENDER / KASARIAN Mobile No: Work Address: Work Address: Civil Status: Single Married Email Address: Office No: 09075490076 WES_2986@YAHOO.COMWidow/er Legally Separated Annulled Email Address: Husband: MANOLITO FLORENTINO DE ASIS Office No: FILIPINO Name of Wife / Father: Citizenship: Maiden/Single Name Name of Father: Citizenship: FILIPINO Complete Address: of DANILO BALUYOT BAGTAS Tel. No: Citizenship:

Mother: Maiden/Single Name of Present Occupation: Mobile No: Citizenship: FILIPINO IRENE DIMALIWAT QUINSINADA Mother: Citizenship Acquired By: Purpose of Travel: Work Address: Birth Election Marriage Naturalization Tour Seaman Business Migration Citizenship Acquired By: Purpose of Travel: Email Address: Office No: R.A.9225 Others: Study Work Others: ______________ Election ________________________ Marriage Naturalization Tour Seaman Business Migration X Birth Name of Father: Citizenship: R.A.9225 Others: ________________________ Study X Work Others: ______________ Maiden/Single Name of Citizenship: Are you Have you ever been issued a Philippine Passport? Mother: a holder of a foreign passport? Yes No Yes Are you a holder of a foreign passport? Have you ever been issued a Philippine Passport? No Citizenship Acquired By: Purpose of Travel: If Yes, from what country? ___________________ No If Yes, latest passport number? _______________ No Yes X Yes X Birth Election Marriage Naturalization Tour Seaman Business Migration If Yes, from what country? ___________________ If Yes, latest passport number? _______________ R.A.9225 Others: ________________________ Study Work Others: ______________ Date of issue ________ Place of issue _________ AreThis serves as Affidavit of Support and Consent to Travel you a holder of a foreign passport? (for Applicants below 18 years old ONLY) No This serves as Affidavit of Support and ConsentYes to Travel Name of minor's (for Applicants below 18 years old ONLY) If Yes, from what traveling companion: country? ___________________
Name of minor's Companion's traveling companion: Relationship: Companion's Address / Contact Relationship: Number: Address / serves as Affidavit of Support and Consent to Travel This Contact Number: (for Applicants below 18 years old ONLY) Name of minor's traveling companion: Signature

Date of issue ________ Place of issue _________ Have you ever been issuedAffidavit of Loss This serves as a Philippine Passport? Lost Passport Number: No This serves as Affidavit of Loss Yes Issued on: Lost Passport Number: If Yes, latest passport number? _______________
Issued by: Issued on: Date by: Issued of issue Datelost: Lost lost: Date due to: Lost due to: This serves Lost Passport Number: Issued on:

________

Place of issue _________ as Affidavit of Loss

Issued by: Companion's Signature of Parent citizen. 2) The information I provided in this application is true and correct. 3) The supporting Signature of Applicant I SOLEMNLY SWEAR that 1) I am a Filipino or Legal Guardian Date lost: Relationship:

of Parent or Legal Guardian

Signature of Applicant

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 I SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided to: this application is true and correct. 3) The supporting Address / Contact Lost that in allowed to hold only one Philippine passport at any given time. 6) I am aware due making false statements in passport application furnishing Number: 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 falsified or forged documents in support thereof are punishable by law. allowed to hold only one Philippine passport at any given time. 6) I am aware that making false statements in passport application furnishing falsified or forged documents in support thereof are punishable by law.

Signature of Parent or Legal Guardian

Signature of Signature of Applicant Applicant

IREMARKS:SWEAR that 1) I am a Filipino citizen. 2) The information I provided in thisSignature of true and correct. 3) The supporting SOLEMNLY application is Applicant 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 REMARKS: allowed to hold only one Philippine passport at any given time. 6) I am aware that making false statements in passport application furnishing FOR STRICT COMPLIANCE: Please print name and affix initials. falsified or forged documents in support thereof are punishable by law.

FOR STRICT COMPLIANCE: Please print name and affix initials. Processor: Encoder: RECEIVED Processor: CANCELLED PASSPORT:Encoder: REMARKS: RECEIVED CANCELLED PASSPORT: FOR ADMINISTRATIVE USE ONLY:

Signing Officer:

RECEIVED NEW PASSPORT: Signing Officer: Signature of Applicant RECEIVED NEW PASSPORT:

FOR ADMINISTRATIVE USE Please print name and affix initials. STRICT COMPLIANCE: ONLY: Processor: Encoder: Signing Officer: RECEIVED NEW PASSPORT:

RECEIVED CANCELLED PASSPORT: FOR ADMINISTRATIVE USE ONLY: