Application For A U.s. Passport Page 5
Download a blank fillable Application For A U.s. Passport in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Application For A U.s. Passport with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6APPLICATION FOR A U.S. PASSPORT
OMB APPROVAL NO. 1405-0004
EXPIRATION DATE: 12-31-2010
ESTIMATED BURDEN: 85 MIN
Attention: see WARNING on page two of instructions
Please select the document (or documents) for which you are applying:
U.S. Passport Book
U.S. Passport Card
The U.S. passport card may only be used for international travel by land or sea between the United States,
Canada, Mexico, the Caribbean and Bermuda.
Please visit our website for detailed information.
R
D
O
DP
1. Name Last
End. #__________
Exp ____________
First & Middle
2. Date of Birth (mm/dd/yyyy)
-
-
4. Place of Birth (City & State or City & Country as it is presently known)
5. Social Security Number
3. Sex
-
-
M
F
6. Mailing Address: Street/RFD # or P.O. Box
Apartment or unit #
City
State
Zip Code (Zip + 4 if known)
In Care Of or Country, if applicable
7. Contact Phone Number
8. Email Address (Optional)
Home
Cell
-
-
Work
9. Have You Ever Used A Different Name (Maiden, Previous Marriage, Legal Name Change)? If yes, please complete.
(Attach additional pages if needed)
1.
2.
10. Parents’ Information
Father’s Name - First & Middle
Last
Date of Birth (mm/dd/yyyy)
Father’s Place of Birth
U.S. Citizen?
Yes
No
Mother’s Name - First & Middle
Last (Maiden)
Date of Birth (mm/dd/yyyy)
Mother’s Place of Birth
U.S. Citizen?
Yes
Submit two recent,
color photographs
No
>
CONTINUE TO PAGE 2
>
DO NOT SIGN APPLICATION UNTIL REQUESTED TO DO SO BY PERSON ADMINISTERING OATH.
I declare under penalty of perjury all of the following: 1)I am a citizen or non-citizen national of the United States and have not, since acquiring U.S. citizenship or nationality,
performed any of the acts listed under “Acts or Conditions” on the reverse side of this application (unless explanatory statement is attached); 2)the statements made on the
application are true and correct; 3)I have not knowingly and willfully made false statements or included false documents in support of this application; 4)the photograph
submitted with this application is a genuine, current, photograph of me; and 5)I have read and understood the warning on page two of the instructions to the application form.
Identifying Documents - Applicant or Father (if identifying minor)
Military
Driver’s License
Passport
Other ____________________
x ____________________________________________________
Expiration
Issue
Place of
Applicant’s Signature - age 16 and older
Date _______________________
Date __________________________
Issue _________________
Name ______________________________
ID No ______________________________
x ____________________________________________________
Identifying Documents - Mother (if identifying minor)
Father’s/Legal Guardian’s Signature (if identifying minor)
Driver’s License
Passport
Military
Other ____________________
Issue
Expiration
Place of
Date _______________________
Date __________________________
Issue _________________
x ____________________________________________________
Mother’s/Legal Guardian’s Signature (if identifying minor)
Name ______________________________
ID No ______________________________
Acceptance Agent
(Vice) Consul USA
Passport Services Staff Agent
Facility Name/Location ___________________________
Subscribed and sworn to (affirmed) before me:
-
Facility/Agent ID Number
______________________________________
Date ____________
(Seal)
Signature of person authorized to accept applications
PPT Fee________
EF________
Postage________
Other________
DS-11 02-2008
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application For A U.s. Passport Corrections, Name Change Within 1 Year Of Passport Issuance, And Limited Passport Holders
Life
U.s. Passport Renewal From Canada By Appointment Order Form, Form Ds11 - Application For A Us Passport From Canada
Life
Related Categories
Parent category: Life