Application for a U.S. Passport
18. Travel Plans
Departure Date (mm/dd/yyyy)
Return Date (mm/dd/yyyy)
Countries to be Visited
City
Zip CodeState
Apartment/Unit
19. Permanent Address - If P.O. Box is listed under Mailing Address or
if residence is different from Mailing Address.
Stre et/RFD # or URB ( No P.O. Box)
13. Occupation (if age 16 or older) 14. Employer or School (if applicable)
Home
Cell
Work
12. Additional Contact Phone Number
Mother/Father/Parent - First & Middle Name
Last Name (at Parent's Birth)
Date of Birth (mm/dd/yyyy)
Place of Birth
10. Parental Information
Male
Female
Yes
No
U.S. Citiz e n?Sex
21. Have you ever applied for or been issued a U.S. Passport Book or Passport Card?
Name as printed on your most recent passport book
Yes No If yes, complete the rema ining items in #21.
PLEASE DO NOT WRITE BELOW THIS LINE - FOR ISSUING OFFICE ONLY
Name as it appears on citizenship evidence
Birth Certificate SR CR City F iled: Issued:
Passport C/R S/R Per PIERS #/DOI:
Attached:
* DS 11 C 09 2013 2 *
P/C of ID
DS-5520DS-3053 DS-64 DS-5513
Citz W/S
DS-10
DS-71
DS-86
IRL CIS Ver
20. Emergency Contact - Provide the information of a person not traveling with you to be contacted in the event of an emergency.
Name
Address: Street/RFD # or P.O. Box Apartment/Unit
City State Zip Code Phone Number Relationship
DS-11 09-2013
Page 2 of 2
Date of Birth (mm/dd/yyyy)Name of Applicant (Last, First, & Middle)
Name as printed on your most recent passport card
-
-
Mother/Father/Parent - First & Middle Name
Last Name (at Parent's Birth)
Date of Birth (mm/dd/yyyy) Place of Birth
Male
Female
Yes
No
U.S. Citizen?Sex
-
-
--
Report of Birth Filed/Place:
Nat. / Citz. Cert. USCIS USDC Date/Place Acquired: A#
Other:
If yes, complete the remaining items in #11.
Date of Marriage
(mm/dd/yyyy)
11. Have you ever been married?
Full Name of Current Spouse or Most Recent Spouse Date of Birth (mm/dd/yyyy)
Have you ever been widowed or divorced?
Place of Birth
Yes
No
Widow/Divorce Date
(mm/dd/yyyy)
Yes No
Yes
No
U.S. Citizen?
- -
15. Height 16. Ha i r Color 17. Eye Color
Status of your most recent passport book:
Submitting with application
Stolen Lost In my possession (if expired)
Status of your most recent passport card:
Submitting with application
Stolen
Lost
In my possession (if expired)
Most recent passport book number Most recent passport book issue date (mm/dd/yyyy)
Most recent passport card number Most recent passport card issue date (m m/dd/yyyy)
P/C of Citz
Page 6/6
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