Form Ds-82 - Application For A U.s. Passport By Mail (Page 6 of 6) in pdf

Form Ds-82 - Application For A U.s. Passport By Mail Page 6

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.

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