Application for a U.S. Passport
4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.)
APPLICATION FOR A U.S. PASSP ORT
x
x
Mother/Fath er/Parent/Legal Guard ian 's Signatu re (if identifying m inor)
x
Mother/Fath er/Parent/Legal Guard ian 's Signatu re (if identifying m inor)
App licant 's Legal Signatu re - age 16 and older
DO NOT SIGN APPLICATION UNTIL REQUESTED TO DO SO BY AUTHORIZED AGENT
OMB CONTR O L NO . 1405- 000 4
OMB EXPIRATION DATE: 01-31-2017
ESTIMATED BURDEN: 95 MIN
Please Print Legibly Using Black Ink Only
Attention: Read WARNING on page 1 of instructions
Please select the document(s) for which you are applying:
D
ODep
End. #
Exp.
First Middle
-
-
MF
A. B.
I declare under penalty of perjury all of the following: 1) I am a citizen or non-citizen national of the United States and
have not, since acquiring U.S. citizenship or nationality, performed any of the acts listed under "Acts or Conditions" on
page four of the instructions of this application (unless explanatory statement is attached); 2) the statements made on the
application are true and correct; 3) I have not knowingly and willfully made false statements or included false documents
in support of this application; 4) the photograph attached to this application is a genuine, current photograph of me; and
5) I have read and understood the warning on page one of the instructions to the application form.
(Seal)
Acceptance Agent
(Vice) Consul USA
Passport Staff Agent
* DS 11 C 09 2013 1 *
Bk
Postage Execution
Other
EF
For Issuing Office On ly
Date
Facility Name/Location
Identifying Documents - Applicant or Mother/Father/Parent on Second Signature Line (if identifying minor)
DS-11 09-2013
Page 1 of 2
DOTS
Facility ID Number
Agent ID Number
3. Sex
Signature of per son auth ori zed to accept appli cations
STOP! CONTINUE TO PAGE 2
U.S. Passport Card
U.S. Passport Book
Note: The 52 page option is for those who frequently travel abroad during the passport validi ty period, and is recommended
for applicants who have prev i ously required the addition of visa pages.
52 Page Book (Non-Standard)
--
City Zip Code
6. Email Address (e.g., my_em [email protected]ain.com)
@
7. Primary Contact Phone Number
--
1. Name Last
Country, if outside the United StatesState
9. List all ot her names you have used. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed)
Address Line 2: Clearly label Apartment, Company, Suite, Unit, Building, Floor, In Care Of or Attention if applicable. (e.g., In Care Of - Jane Doe, Apt # 100)
8. Mailing Address: Line 1: Street/RFD#, P.O. Box, or URB.
5. Social Security Number
Card
2. Date of Birth (mm/dd/yyyy)
Both
28 Page Book (Standard)
The U.S. passport card is not valid for international air travel. For more information see page 1 of instructions.
Driver's License
ID No
Passport Military Other
Country of
Issuance
State Issued ID Card
Identifying Documents - Applicant or Mother/Father/Parent on Third Signature Line (if identifying minor)
STAPLE 2" x 2" STAPLE
STAPLE 2" x 2" STAPLE
Attach a color photograph
taken within the last six months
Name
Driver's License
ID No
Issue Date
(mm/dd/yyyy)
Exp. Date
(mm/dd/yyyy)
State of
Issuance
Passport Military Other
Country of
Issuance
State Issued ID Card
Name
Name of courier com pany (if applicable)
Issue Date
(mm/dd/yyyy)
Exp. Date
(mm/dd/yyyy)
State of
Issuance
Page 5/6
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