E Passport Application Form

REPUBLIC OF THE PHILIPPINES DEPARTMENT OF FOREIGN AFFAIRS MANILA E-PASSPORT APPLICATION PLEASE PROVIDE CORRECT INFORMATION AND DO NOT LEAVE SPACES BLANK

LAST NAME/APELYIDO

MIDDLE NAME/GITNANG PANGALAN

FIRST NAME/PANGALAN ( JR/II/III )

PLACE OF BIRTH/POOK NG KAPANGANAKAN

DATE OF BIRTH ( EX. 01 January 2000 )

GENDER/KASARIAN

MALE

FEMALE

PETSA NG KAPANGANAKAN

Civil Status:

Single

Married

Widower

Legally Separated

Name of Husband/Wife

Annulled

Citizenship First Name

Middle Name

Last Name

Complete Address: Contact Number Contact Number

Present Occupation:

Work Address: Email Address: Name of Father

Citizenship First name

Middle Name

Last Name

First name

Middle Name

Last Name

Maiden/Single Name of Mother

Citizenship

Citizenship Acquired By: Birth R. A. 9225

Purpose of Travel

Election Others:

Marriage

Are you a Holder of a Foreign Passport

Naturalization

YES

Tour Study

NO

Seaman Work

Business Others

Migration

yes

Have you ever been issued a Philippine Passport?

If Yes, latest Passport Number: Date of Issue:

If Yes, what Country? This serves as Affidavit Of Support and Consent to Travel applicants below 18 years old only

Place of Issue: This serves as an Affidavit of Loss

Lost Passport Number: Issued On:

Name of Minor's Travelling Companion:

Relationship:

Date Lost

Address/Contact Number:

Lost Due to:

Issued By:

Signature of Parent/Legal Guardian

Signature of Applicant

I SOLEMNY SWEAR that 1) I am a Filipinocitizen. 2)The information I provided in this application is true and correct.

3) The supporting documents

attached are authentic. 4) I have not been issued a passport under any other name. 5) I am aware that under the law, I am allowed to hold only one Philippine Passport at any given time. 6) I am aware that making false statements in passport application furnishing falsified or forged document in support thereof are punishable by law.

Signature of Applicant REMARKS: FOR STRICT COMPLIANCE: Please print name and affix initials: Processor:

RECEIVED CANCELLED PASSPORT:

Encoder:

Signing Officer:

RECEIVED NEW PASSPORT:

no