Name of Applicant
Date of Birth
(Last, First, Middle, Suffix)
(mm-dd-yyyy)
17. Travel Plans
Date of Trip (mm-dd-yyyy)
Length of Trip
Countries to be Visited
18. Emergency Contact
- Provide the information of a person not traveling with you to be contacted in the event of an emergency.
Name
Street / RFD Number
Apartment Number
City
ZIP Code
State
Telephone
E-Mail Address
Relationship
(Optional)
(
)
NOTE
You must sign and date this application in the designated area below!
19. Oath & Signature
I declare under penalty of perjury that I am a United States citizen (or non-citizen national) and have not, since acquiring United State citizenship (or
U.S. nationality), performed any of the acts listed under "Acts or Conditions" on the reverse of this application form (unless explanatory statement is
attached). I declare under penalty of perjury that the statements made on this application are true and correct.
X
Applicant's Signature
Date (mm-dd-yyyy)
DO NOT WRITE BELOW - FOR PASSPORT SERVICES USE ONLY - DO NOT WRITE BELOW
Evidence of Name Change
Marriage Certificate
Court Order
Document Issue Date
Place of Issue
Issuing Office/Court
Previous Name
Current Name
APPLICATION APPROVAL
FEE
EXEC.
EF
OTHER
DS-82
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