Republic Of Texas Passport Form - Nation Of Texas printable pdf download

Republic of Texas Passport Form

(Form RTPF-031119)

(Please read instructions on Page 2, BEFORE ﬁlling out this Form)

1a. Applicant’s Surname(s) or Family Name(s) ______________________________________________________________________

1b. Given Name(s) ___________________________________________________________, a.k.a: ___________________________

Male

Female

(Circle One)

Status: Single

Married (Circle One)

4a. Domicile (Street Address) _____________________________________________________________________________________

4b. Town ______________________________________ County ____________________ 4c. email: __________________________

4d. Mailing Location (if different from above) ________________________________________________ ZIP [

]

5a. Home Phone ____________________________________ 5b. Emergency Phone ________________________________________

6. Present (former if retired) Occupation ______________________________________________________________________________

7a. Place of Birth (Town, County or Municipality, State or Province, and Country) ___________________________________________

_________________________________________________________________________________________________________________

7b. Date of Birth (or conception, if preferred ) _________________________________________________________________________

8a. Height (ft/in or Metric) _______________________ 8b. Eye Color ___________________ 8c. Hair Color ____________________

9a. Father’s Full Name ____________________________________________________________________________________________

9b. Father’s Birth Date __________________________________ 9c. Father’s Nationality _____________________________________

10a. Mother’s Full Name ___________________________________________________________________________________________

10b. Mother’s Birth Date _______________________________ 10c. Mother’s Nationality ____________________________________

11. Spouse’s Full Name ____________________________________________________________________________________________

(Include maiden name, if applicable)

12. AVERMENT: I have declared my Texian Nationality, in writing, on (or about) _______________________ . Since declaring to be a Texian National, I have not

been naturalized as a citizen/national of any other nation/state, taken an oath or made an afﬁrmation or other formal declaration of allegiance to, or served in the armed

forces of, accepted or performed the duties of any ofﬁce, post, or employment under the government of any other nation/state or political subdivision thereof, nor made

a formal renunciation of Texian nationality either in the Republic of Texas, or before a diplomatic or consular ofﬁcer of the Republic of Texas or before an ofﬁcer or

representative of any other nation/state, nor attempted to overthrow the lawful government of Texas, nor borne arms against, the Republic of Texas, nor conspired with

anyone to overthrow, put down, or to destroy, the lawful government of the Republic of Texas. I understand that the Republic of Texas Passport does not authorize me to

visit other countries, but only to return to Texas. It is my responsibility to see that all requirements to travel to/in foreign countries are fulﬁlled. GOOD CONDUCT: I

aver that I have not intentionally injured or damaged any living soul, except in defense of life or limb and that I am not wanted for any common-law crime in any

country. I authenticate the above information under penalty of perjury, subject to common law.

________________________________________________________

13b. ____________________________________________

13a. Authentication (Signature) of Applicant or Guardian

Date Signed

_____________________________________________________

________________________________________________

14a. Witness #1 Signature

15a. Witness #2 Signature

_____________________________________________________

________________________________________________

14b. Print Name of Witness #1

15b. Print Name of Witness #2

_____________________________________________________

________________________________________________

14c. Town and county of domicile (Witness #1)

15c. Town and county of domicile (Witness #2)

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FOR OFFICIAL USE ONLY - DO NOT WRITE BELOW THIS LINE.

Date Issued: ________________________________________

Passport No. ____________________________________________

__________________________________________________

_______________________________________________

Signature of Processing Ofﬁcial

Name and Title of Processing Ofﬁcial

PMO

CHK

SIL

FRN