Application For A U.s. Passport Page 6
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6Name of Applicant (Last, First & Middle)
Date of Birth (mm/dd/yyyy)
11. Height
12. Hair Color
13. Eye Color
14. Occupation
15. Employer
16. Additional Contact Phone Numbers
Home
Cell
Home
Cell
Work
___________
Work
___________
17. Permanent Address: Street/RFD # (No P.O. Box)
Apartment or unit #
City
State
Zip Code
18. Emergency Contact - Provide the information of a person not traveling with you to be contacted in the event of an emergency.
Name
Address: Street/RFD # or P.O. Box
Apartment or unit #
City
State
Zip Code
Phone Number
Relationship
19. Travel Plans
Date of Trip (mm/dd/yyyy)
Length of Trip
Countries to be visited
20. Have you ever been married?
Yes
No
If yes, complete the remaining items in #20.
Date of marriage
Date (mm/dd/yyyy)
Current spouse’s or most recent former spouse’s name
Place of birth
(mm/dd/yyyy)
Widowed?
Divorced?
U.S. Passport Book
21. Have you ever been issued a
?
Yes
No
If yes, complete the remaining items in #21.
Your name as listed on your most recent passport book
Most recent passport book number
Status of your most recent passport book
Approximate date your most recent passport book
was issued or date you applied (mm/dd/yyyy)
In My Possession
Stolen
Lost
Other ____________________
U.S. Passport Card
22. Have you ever been issued a
?
Yes
No
If yes, complete the remaining items in #22.
Your name as listed on your most recent passport card
Most recent passport card number
Status of your most recent passport card
Approximate date your most recent passport card
was issued or date you applied (mm/dd/yyyy)
In My Possession
Stolen
Lost
Other ____________________
STOP! PLEASE DO NOT WRITE BELOW THIS LINE
FOR ISSUING OFFICE ONLY
Both
Sole Parent
Name as it appears on citizenship evidence ________________________________________________
Birth Certificate
SR
CR
City
Filed/Issued:
Report of Birth
240
545
1350
Filed/City:
Naturalization / Citizenship Certificate
A#
Date Acquired:
Passport
Issue Date:
Other:
Attached:
DS-11 02-2008
Page 2 of 2
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