Passport Application Form printable pdf download

FSM FORM 5001B-REVISED FORM 5001A

FSM PASSPORT APPLICATION FORM

Applicant Photo

FOR OFFICIAL USE ONLY

Applicant must complete this form and forward it to the

Division of Immigration & Labor, Department of Justice,

Document Issued On: ______________

FSM National Government, Palikir, Pohnpei FM 96941

1 3/16 x 1 ¾

Issuing Official:___________________

PLEASE FOLLOW INSTRUCTIONS

Type of Passport: [ ] Ordinary [ ] Official [ ] Diplomatic

Applicant Information

Name: ___________________________________________

______________________

________________________________________________

Last Name

Middle Initial

First Name

Other Names You Have Used:_________________________________________________________________________________________________________

Date of Birth: __________________________________ Gender

[ ] Miss

[ ] Mrs.

[ ] Ms.

[ ] Mr.

Height: ________________________ Feet _____________________Inches

Hair Color____________________ Eye Color ______________________

Birth Place: ______________________________________ Home Address:____________________________________________________________________

Current Postal Address:______________________________________________________________________________________________________________

Email Address _____________________________________________________________ Phone Number ___________________________________________

Have you ever been issued a foreign passport or FSM passport? [ ] Yes [ ] No

If yes, country of issuance, date issued and passport number_________________________________________________________________________________

Basis of FSM citizen: [ ] Birth [ ] Naturalization [ ] Other means (Provide prove)

Father Information

Last Name:___________________________________ First Name:______________________________________ Middle Name: _______________________

Birthdate: _________________________________ Birthplace: ________________________________________ Is your father FSM citizen? [ ] Yes [ ] No

If no what nationality: __________________________________________________________________________

Mother Information

Last Name:__________________________________ First Name:_______________________________________ Middle Name:_______________________

Birthdate: ________________________________ Birthplace: ________________________________________ Is your mother FSM citizen? [ ] Yes [ ] No

If no what nationality: __________________________________________________________________________

Signature of Applicant Required (Do not sign in the box for infant and adult who cannot

Sign)

Please sign within the box. Signature must not touch box border lines.

Signature of parent or guardian if applicant under age 14 or unable to sign application.____________________________________________________________

Subscribed and sworn to before me this ____________day of ______________ 20

NOTARY PUBLIC SEAL

I hereby certify that I have reviewed the application and found to be complete and I am satisfied that the applicant is a citizen of the Federated States of

Micronesia, and that he/she does not owe allegiance to any foreign country.

____________________________________ _____________________

FSM Immigration Reviewing Officer

Date

Passport Application Form

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