Fillable Printable Application for A United States Passport
Fillable Printable Application for A United States Passport
Application for A United States Passport
WARNING: False statemen ts made kno wingly and willfully in passport applications, including affida vits or other documents sub mitted to sup por t
this application, are punishable by fine and/or imprisonment under U .S. law including the provisions of 18 U.S.C. 1001, 18 U .S.C. 1542, and/or 18
U.S.C. 1621. Alteration or mutilation of a passport issued pursuant to this application is punishable by fine and/or imprisonment under the
provisions of 18 U.S.C. 1543. The use of a passport in violation of the restrictions contained herein or o f the passport regulations is punishable
by fine and/or imprisonment under 18 U.S.C. 1544. All statements and documents are subject to verification.
IMPORTANT NOTICE TO APPLICANTS WHO HAVE HAD A PREVIOUS U.S. PASSPORT BOOK AND/OR PASSPORT CARD
AS DIRECTED BY PUBLI C LAW 106-113 AND 22 CFR 51.28:
To submit an application for a child under age 16 both parents or the child's legal guardian(s) must appear
and present the fo llowing:
- Evidence of the child's U.S. citizenship;
- Evidence of the child's relationship to parents/guardian(s); AND
- Parental/guardian government-issued identification.
IF ONLY ONE PARENT APPEARS, YOU MUST ALSO SUBMIT ONE OF THE FOLLOWING:
- Second parent's notarized written statement or DS-3053 (including the child's full name and date of birth) consenting to the passport issuance for t he child.
The notarized statement cannot
be more than three months old and must be signed and notarized on the same day, and must come with a photocopy of
the front and back side of the second parent's government-issued photo identification; OR
- Second parent’s death certificate if second parent is deceased; OR
- Primary evidence of sole authority to apply; OR
- A written statement or DS-5525 (made under penalty of perjury) explaining in detail the second parent's unavailability.
AS DIRECTED BY REGULATION 22 C.F.R. 51.21 AND 51.28:
- Each minor child applying for a U.S. passport book and/or passport card must appear in person.
SPECIAL REQUIREMENTS FOR CHILDREN
FAILURE TO PROVIDE INFORMATION REQUESTED ON THIS FORM, INCLUDING YOUR SOCIAL SECURITY NUMBER,
MAY RESULT IN SIGNIFICANT PROCESSING DELAYS AND/OR THE DENIAL OF YOUR APPLICATION.
INFORMATION, QUESTIONS, AND INQUIRIES
U.S. PASSPORTS, EITHER IN BOOK OR CARD FORMAT, ARE ISSUED ONLY TO U.S. CITIZENS OR NON-CITIZEN NATIONALS. EACH PERSON
MUST OBTAIN HIS OR HER OWN U.S. PASSPORT BOOK OR U.S. PASSPORT CARD. THE PASSPORT CARD IS A U.S. PASSPORT ISSUED IN
CARD FORMAT. LIKE THE TRADITIONAL U.S. PASSPORT BOOK, IT REFLECTS THE BEARER'S ORIGIN, IDENTITY, AND NATIONALITY AND IS
SUBJECT TO EXISTING PASSPORT LAWS AND REGULATIONS. UNLIKE THE U.S. PASSPORT BOOK, THE U.S. PASSPORT CARD IS VALID
ONLY FOR ENTRY TO THE UNITED STATES AT LAND BORDER CROSSINGS AND SEA PORTS OF ENTRY WHEN TRAVELING FROM CANADA,
MEXICO, THE CARIBBEAN, AND BERMUDA. THE U.S. PASSPORT CARD IS NOT VALID FOR INTERNATIONAL AIR TRAVEL.
Please visit our website at travel.state.gov. In addition, you may contact the National Passport Information
Center (NPIC) toll-free at 1-877-487-2778 (TDD: 1-888-874-7793) or by email at [email protected]
. Customer
Service Representatives are available Monday-Friday 8:00a.m.-10:00p.m. Eastern Time (excluding federal
holidays). Automated information is available 24 hours a day, 7 days a week.
APPLICATION FOR A U.S. PASSPORT
PLEASE DETACH AND RETAIN THIS INSTRUCTIO N SHEET FOR YOUR RECORDS
I applied:
DS-11 09-2013
Place:
Date:
Instruction Page 1 of 4
WHAT TO SUBMIT WITH THIS FORM:
1. PROOF OF U.S. CITIZENSHIP (Evidence of U.S. citizenship that is not damaged, altered, or forged will be returned to you.)
2. PROOF OF IDENTITY (You must present your original identification AND submit a photocopy of the front and back side with your passport application.)
3. RECENT COLOR PHOTOGRAPH (Photograph must meet passport requirements – full front view of the face and 2x2 inches in size.)
4. FEES (Please visit our website at travel.state.gov
for current fees.)
WHERE TO SUBMIT THIS FORM:
Please complete and submit this application in person to one of the following acceptance agents: a clerk of a federal or state court of record or a judge or
clerk of a probate court accepting applications; a designated municipal or county official; a designated postal employee at an authorized post office; an agent
at a passport agency (by appointment only); or a U.S. consular offi cial at a U.S. Embassy or C onsulate, if abroad. To find your nearest acceptance facility,
visit travel.state.gov
or contact the National Passport Information Center at 1-877-487-2778.
LOST OR STOLEN - You are required to submit a Form DS-64, Statement Regarding a Lost or Stolen U.S. Passport, when your valid or potentially
valid U.S. passport book and/or passport card cannot be submitted with this application.
IN MY POSSESSION
- If your most recent U.S.passport book and/or passport card was issued less than 15 years ago, and you were over the age of
16 at the time of issuance, you may be eligible to use Form DS-82 to renew your passport by mail. If your most recent passport is valid and needs
additional pages, you can submit your passport, form DS-4085, and the current fee.
See page 2 of the instructions for detailed information on the completion and submission of this form.
APPLICATION FOR A U.S. PASSPORT
The passport p rocessing, executio n, and security fees may be paid in any of the follow ing forms: Checks (personal, certified, or traveler' s) with the applicant's full name
and date of birth printed on the front; major credit card (Visa, Master Card, American Express, and Discover); bank draft or cashier's check; money order (U.S. Postal, international,
currency exchange), or if abroad, the foreign currency equivalent, or a check drawn on a U.S. bank. All fees should be payable to the "U.S. Department of State
" or if abroad, the
appropriate U.S. Embassy or U.S. Consulate. When applying at a designated acceptance facility, the execution fee will be paid separately and should be made payable to the
acceptance facility. NOTE: Some designated acceptance facilities do not accept credit cards as a form of payment.
For faster processing, you may request expedited service. Please include the expedite fee in your payment. Our website contains updated information regarding fees and
processing times for expedited service. Expedited service is available only in the United States.
If you desire OVERNIGH T DELIVERY SERVICE for the return of your passport, please include the appropriate fee with your payment.
An additional fee will be charged when, upon your request, the U.S. Department of State verifies issuance of a previous U.S. passport or Consular Report of Birth Abroad
because you are unable to submit evidence of U.S. citizenship.
For applicants with U.S. government or military authorization for no-fee passports, no fees are charged except the execution fee
when applying at a designated
acceptance facility.
1. PROOF OF U.S. CITIZENSHIP
You may submit items such as the following containing your signature AND a photograph that is a good likeness of you: previous or current U .S. passport book; previous or current
U.S. passport card; driver's license (not temporary or learner's license); Certificate of Naturalization; Certificate of Citizenship; military identification; or federal, state, or municipal
government employee identification card. Temporary or altered documents are not acceptable
.
You must establish your identity to the satisfaction of the acceptance agent and Passport Services. We may ask you to provide additional evidence to establish your identity. If
you have changed your name, please see travel.state.gov
for instructions.
IF YOU CANNOT PROVIDE DOCUMENTARY EVIDENCE OF IDENTITY as stated above, you must appear with an IDENTIFYING WITNESS who is a U.S. citizen, non-citizen
U.S. national, or permanent resident alien who has known you for at least two years. Your witness must prove his or her identity and complete and sign an Affidavit of Identifying
Witness (Form DS-71) before the acceptance agent. You must also submit som e identification of your own.
Submit a color photograph of you alone, sufficiently recent to be a good likeness of you (taken within the last six months), and 2x2 inches in size. The image size measured from
the bottom of your chin to the top of your head (including hair) should not be less than 1 inch, and not more than 1 3/8 inches. The photograph must be color, clear, with a full front
view of your face, and printed on photo quality paper with a plain light (white or off-white) background. The photograph must be taken in normal street attire, without a hat, head
covering, or dark glasses unless a signed statement is submitted by the applicant verifying the item is worn daily for religious purposes or a signed doctor's statem ent is submitted
verifying the item is used daily for medical purposes. Headphones, "bluetooth", or similar devices must not
be worn in the passport photograph. Any photograph retouched so that
your appearance is changed is unacceptable. A snapshot, most vending machine prints, and magazine or full-length photographs ar e unacceptable. A digital photo must meet the
previously stated qualifications, and will be accepted for use at the discretion of Passport Services. Vi sit our website at travel.state.gov
for details and information.
CURRENT FEES ARE LISTED ON OUR WEBSITE AT TRAVEL.STATE.GOV. BY LAW, THE PASSPORT FEES ARE NON-REFUNDABLE.
DS-11 09-2013
2. PROOF OF IDENTITY
3. RECENT COLOR PHOTOGRAPH
4. FEES
Instruc t ion Page 2 of 4
APPLICANTS BORN IN THE UNITED STATES: Submit a previous U.S. passport or certified birth certificate. Passports that are limited in validity will need to be supplemented
by other evidence. A birth certificate must include your full name, date and place of birth, sex, date the birth record was filed, the seal or other certification of the official custodian
of such records (state, county, or city/town office), and the full names of your parent(s).
- If the birth certificate was filed more than 1
year after the birth: It must be supported by evidence described in the next paragraph.
- If no birth record exists
: Submit a registrar's notice to that effect. Also, submit a combination of the evidence listed below, w hich should include your given name and surname,
date and/or place of birth, and the seal or other certification of the office (if customary), and the signature of the issuing official.
A hospital birth record;
An early baptismal or circum cision certificate;
Early census, school, medical, or family Bible records;
Insurance files or published birth announcements (such as a newspaper article); and
Notarized affidavits (or DS-10, Birth Affidavit) of older blood relatives having knowledge of your birth may be submitted in addition to some of the records
listed above.
APPLICANTS BORN OUTSIDE THE UNITED STATES: Submit a previous U.S. passport, Certificate of Naturalization, Certificate of Citizenship, Report of Birth Abroad, or
evidence described below:
- If you claim citizenship through naturalization of parent(s)
: Submit the Certificate(s) of Naturalization of your parent(s), your foreign birth certificate (and official translation if the
document is not in English), proof of your admission to the United States for permanent residence, and
your parents' marriage/certificate and/or evidence that you were in the
legal and physical custody of your U.S. citizen parent, if applicable.
- If you claim citizenship through birth abroad to at least one U.S. citizen parent
: Submit a Consular Report of Birth (Form FS-240), Certification of Birth (Form DS-1350 or
FS-545), or your foreign birth certificate (and official translation if the docum ent is not in English), proof of U.S. citizenship of your parent, your parents' marriage certificate, and
an affidavit showing all of your U.S. citizen parents' periods and places of residence/physical presence in the United States and abroad before your birth.
- If you claim citizenship through adoption by a U.S. citizen parent(s)
: Submit evidence of your permanent residence status, full and final adoption, and your U.S. citizen
parent(s) evidence of legal and physical custody. (NOTE: Acquisition of U.S. citizenship for persons born abroad and adopted only applies if the applicant was born on or after
02/28/1983.)
ADDITIONAL EVIDENCE: You must establish your citizenship to the satisfaction of the acceptance agent and Passport Services. We may ask you to provide
additional evidence to establish your claim to U.S. citizenship. Visit travel.state.gov
for details.
You may receive your newly issued passport book and/or card and your returned citizenship evidence in two separate mailings. If you are applying for both a U.S.
passport book and passport card, you may receive three separate mailings; one with your returned cit izenship evidence, one w ith your newly issued passport book,
and one wi th your new l y issued passpo rt card.
If you are 16 years of age or older: Your U.S. passport will be valid for 10 years from the date of issue except where limited by the Secretary of State to a shorter period.
(See information below about the additional cost for expedited service.)
If you are under 16 years of age: Your U.S. passport will be valid for five years from the date of issue except where limited by the Secretary of State to a shorter period.
(See information below about the additional cost for expedited service.)
DS-11 09-2013
FEDERAL TAX LAW
Section 6039E of the Internal Revenue Cod e (26 U.S.C. 6039E) requires you to provide your Social Security number (SSN), if you have one, when
you apply for or renew a U.S. passport. If you have no t been issued a SSN, enter zeros in box #5 of this form. If you are residing abroad, you must
also provide the name of the foreign country in which you are residing. The U.S. Department of State m ust p rovide your SSN and foreign residence
information to the U.S. Department of Treasury. If you fail to provide the information, you are subject to a $500 penalty enforced by the IRS. All
questions on this matter should be directed to the nearest IRS office.
If you send us a check, it will be converted into an electronic funds transfer (EFT). This means we will copy your check and use the account
information on it to electronically debit your account for the amo unt of the check. The debit fro m your account will usually occur within 24 hours and
will be shown on your regular account statement.
You will not receive your original check back. We will destroy your original check, but we will keep the copy of it. If the EFT cannot be processed for
technical reasons, you authorize us to process the copy in place of your original check. If the EFT cannot be completed because of insufficient
funds, we may try to make the transfer up to two times, and we will charge you a one-time fee of $25, which we will also collect by EFT.
NOTICE TO CUSTOMERS APPLYING OUTSIDE A STATE DEPARTMENT FACILITY
Passport service fees are established by law and regulation (see 22 U.S.C. 214, 22 C.F.R. 22.1, and 22 C.F.R. 51.50-56), and are collected at the
time you apply for the passport service. If the Department fails to receive full payment of the applicable fees because, for example, your check is
returned for any reason or you dispute a passport fee charge to your credit card, the U.S. Department of State will take action to collect the
delinquent fees from you under 22 C.F.R. Part 34, and the Federal Claims Collecti on Standards (see 3 1 C.F.R. Parts 900-904). In accordance with
the Debt Collection Improvement Act (Pub.L . 104-134), if the fees remain unpaid afte r 180 days and no repayment arrangements have been made,
the Department will refer the debt to the U.S. Department of Treasury for collection. Debt collection procedures used by U.S. Department of
Treasury may include referral of the debt to private collection agencies, reporting of the debt to credit bureaus, garnishment of private wages and
administrative offset of the debt by reducing, or withholding eligible federal payme nts (e.g., tax refunds, social security payments, federal retirement,
etc.) by the amount of your debt, including any interest penaltie s or other costs incurred. In addition, non-payment of passport fees may result in the
invalidation of your passport. An invalidated passport cannot be used for travel.
REMITTANCE OF FEES
OTHER USES OF SOCIAL SECURITY NUMBER
For more information regarding reporting a lost or stolen U.S. passport book or passport card and the Form DS-64,
your eligibility to submit a Form DS-82 or how to request additional visa pages, call NPIC at 1-877-487-2778 or
visit travel.state.gov
.
Your Social Security number will be provided to U.S. Department of Treasury, used in connection with debt collection and checked against lists of
persons ineligible or potentially ineligible to receive a U.S. passport, among other authorized uses.
PROTECT YOURSELF AGAINST IDENTITY THEFT!
REPORT YOUR LOST OR STOLEN PASSPORT BOOK OR PASSPORT CARD!
NOTICE TO APPLICANTS FOR OFFICIAL, DIPLOMATIC, OR NO-FEE PASSPORTS
You may use this application if you meet all of the provisions listed on Instruction Page 2, however, you must CONSULT YOUR SPONSORING
AGENCY FOR INSTRUCTIONS ON PROPER ROUTING PROCEDURES BEFORE FORWARDING THIS APPLICATION. Your completed passport
will be released to your sponsoring agency for forwarding to you.
Passport Services will not mail a U.S. passport to a priv ate ad dress outsid e the United States. If you do not liv e a t the address listed in the "mailing address",
then you must put the name of the person and mark it as "In Care Of" in item # 8. If your mailing address changes prior to receipt of your new passport,
please contact the National Passport Information Center.
If you choose to prov ide your email address in Item #6 on this app lication, Passport Services may use that information to contact you in the event there is a
problem with your application or if you need to provide information to us.
SPECIAL NOTICE TO U.S. PASSPORT CARD APPLICANTS ONLY
The maximum number of letters provided for your given name (first and middle) on the U.S. passport card is 24 characters. The 24 characters may be
shortened due to printing restrictions. If both your give n names are more than 24 characters, you must shorten one of your given names you list on item 1 of
this form.
NOTE REGARDING MAILING ADDRESSES
Instruction Page 3 of 4
DS-11 09-2013
ACTS OR CONDITIONS
If any of the below-mentioned acts or conditions have been performed by or apply to the applicant, the portion which applies should be lined out,
and a supplementary explanatory statement under oath (or affirmation) by the applicant should be attached and made a part of this application.
I have not, since acquiring United States citizenship/nationality, been naturalized as a citizen of a foreign state; taken an oath or made an
affirmation or other formal declaration of allegiance to a foreign state; entered or served in the armed forces of a foreign state; accepted or
performed the duties of any office, post, or employment under the government of a foreign state or political subdivision thereof; made a formal
renunciation of nationality either in the United States, or before a diplomatic or consular officer of the United States in a foreign state; or been
convicted by a court or court martial of competent jurisdiction of committing any act of treason against, or attempting by force to overthrow, or
bearing arms against, the United States, or conspi ring to overthrow, put down, or to destroy by force, the government of the United States.
Furthermore, I ha ve no t been convicted o f a federa l or state d rug offense or convicted of a "sex tourism" crimes statute, and I am not the subject o f
an outstanding federal, state, or local warrant of arrest for a felony; a criminal court order forbidding my departure from the United States; a
subpoena received from the United States in a matter involving federal prosecution for, or grand jury investigation of, a felony.
PRIVACY ACT STATEMENT
AUTHORITIES: Collection of this in formation is authorized by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E, Section 236 of the Admiral
James W. Nance and Meg Donovan Foreign Relations Authorization Act, Fiscal Years 2000 and 2001; Executive Order 11295 (August 5, 1966);
and 22 C.F.R. parts 50 and 51.
PURPOSE: We are requesting this information in order to determine your eligibility to be issued a U.S. p assport. Your Socia l Security number is
requested in order to verify your identity. Failure to provide your Social Security number on this form may delay processing of your application.
ROUTINE USES : This information may be disclosed to another domestic governm ent agency, a private contractor, a foreign government a gency,
or to a private person or private employer in acco rdan ce with certain approved routine uses. These routine uses include, but a re not li mited t o , law
enforcement activities, employment verification, fraud prevention, border security, counterterrorism, litigation activities, and activities that meet the
Secretary of State's responsibility to protect U.S. citizens and non-citizen nationals abroad.
More information on the Routine Uses for the system can be found in System of Records Notices State-05, Overseas Citizen Services Records and
State-26, Passport Records.
DISCLOSURE: Providing your Social Security number an d the other informa tion on this form is voluntary, but failure to provide the in formation o n
this form may, given the form's purpose of verification of identity and entitlement to a U.S. passport, result in processing delays or denial of the
passport application.
Failure to provide your Social Security number may also subject you to a penalty enforced by the Internal Revenue Service, as described in the
Federal Tax Law section of the instructions to this form. Your Social Security number will be provided to the Department of the Treasury and may
be used in connection with debt collection, among other purposes as authorized and generally described in this section. Providing your Social
Security number and other information requested on this form is otherwise voluntary.
ELECTRONIC PASSPORT STATEMENT
The U.S. Department of State now issues an "Electronic Passport" book, which contains an embedded electronic chip. The electronic passport
book continues to be proof of the bearer's United States citizenship/nationality and identity, and looks and functions in the same way as a passport
without a chip. The addition of an electronic chip in the back cover enables the passport book to carry a duplicate electronic copy of all information
from the data page. The electronic passport book is usable at all ports-of-entry, including those that do not yet have electronic chip readers.
Use of the electronic format provides the traveler the additional security protections inherent in chip technology. Moreover, when used at
ports-of-entry equipped with electronic chip readers, the electronic passport book provides for faster clearance through some of the port-of-entry
processes.
The electronic passport book does not require special handling or treatment, but like previous versions should be protected from extreme heat,
bending, and from immersion in water. The electronic chip must be read using specially formatted readers, which protects the data on the chip
from unauthorized reading.
The cover of the electronic passport book is printed with a special symbol representing the embedded chip. The symbol will appear in
port-of-entry areas where the electronic passport book can be read.
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this co llection of informa tion is estima ted to average 95 minute s per response, including the time required for searching
existing data sources, gathering the necessary data, providing the information and/or documents required, and reviewing the final collection. You
do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comme nts on the accuracy
of this burden estimate and/or recommendations for reducing it, please send them to: U.S. Department of State, Bureau of Consular Affairs,
Passport Services, Office of Program Management and Operational Support, 2201 C Street NW, Washington, D.C. 20520.
Instruction Page 4 of 4
4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.)
APPLICATION FOR A U.S. PASSP ORT
x
x
Mother/Fath er/Parent/Legal Guard ian 's Signatu re (if identifying m inor)
x
Mother/Fath er/Parent/Legal Guard ian 's Signatu re (if identifying m inor)
App licant 's Legal Signatu re - age 16 and older
DO NOT SIGN APPLICATION UNTIL REQUESTED TO DO SO BY AUTHORIZED AGENT
OMB CONTR O L NO . 1405- 000 4
OMB EXPIRATION DATE: 01-31-2017
ESTIMATED BURDEN: 95 MIN
Please Print Legibly Using Black Ink Only
Attention: Read WARNING on page 1 of instructions
Please select the document(s) for which you are applying:
D
ODep
End. #
Exp.
First Middle
-
-
MF
A. B.
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
page four of the instructions 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 attached to this application is a genuine, current photograph of me; and
5) I have read and understood the warning on page one of the instructions to the application form.
(Seal)
Acceptance Agent
(Vice) Consul USA
Passport Staff Agent
* DS 11 C 09 2013 1 *
Bk
Postage Execution
Other
EF
For Issuing Office On ly
Date
Facility Name/Location
Identifying Documents - Applicant or Mother/Father/Parent on Second Signature Line (if identifying minor)
DS-11 09-2013
Page 1 of 2
DOTS
Facility ID Number
Agent ID Number
3. Sex
Signature of per son auth ori zed to accept appli cations
STOP! CONTINUE TO PAGE 2
U.S. Passport Card
U.S. Passport Book
Note: The 52 page option is for those who frequently travel abroad during the passport validi ty period, and is recommended
for applicants who have prev i ously required the addition of visa pages.
52 Page Book (Non-Standard)
--
City Zip Code
6. Email Address (e.g., my_em ail@domain.com)
@
7. Primary Contact Phone Number
--
1. Name Last
Country, if outside the United StatesState
9. List all ot her names you have used. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed)
Address Line 2: Clearly label Apartment, Company, Suite, Unit, Building, Floor, In Care Of or Attention if applicable. (e.g., In Care Of - Jane Doe, Apt # 100)
8. Mailing Address: Line 1: Street/RFD#, P.O. Box, or URB.
5. Social Security Number
Card
2. Date of Birth (mm/dd/yyyy)
Both
28 Page Book (Standard)
The U.S. passport card is not valid for international air travel. For more information see page 1 of instructions.
Driver's License
ID No
Passport Military Other
Country of
Issuance
State Issued ID Card
Identifying Documents - Applicant or Mother/Father/Parent on Third Signature Line (if identifying minor)
STAPLE 2" x 2" STAPLE
STAPLE 2" x 2" STAPLE
Attach a color photograph
taken within the last six months
Name
Driver's License
ID No
Issue Date
(mm/dd/yyyy)
Exp. Date
(mm/dd/yyyy)
State of
Issuance
Passport Military Other
Country of
Issuance
State Issued ID Card
Name
Name of courier com pany (if applicable)
Issue Date
(mm/dd/yyyy)
Exp. Date
(mm/dd/yyyy)
State of
Issuance
18. Travel Plans
Departure Date (mm/dd/yyyy)
Return Date (mm/dd/yyyy)
Countries to be Visited
City
Zip CodeState
Apartment/Unit
19. Permanent Address - If P.O. Box is listed under Mailing Address or
if residence is different from Mailing Address.
Stre et/RFD # or URB ( No P.O. Box)
13. Occupation (if age 16 or older) 14. Employer or School (if applicable)
Home
Cell
Work
12. Additional Contact Phone Number
Mother/Father/Parent - First & Middle Name
Last Name (at Parent's Birth)
Date of Birth (mm/dd/yyyy)
Place of Birth
10. Parental Information
Male
Female
Yes
No
U.S. Citiz e n?Sex
21. Have you ever applied for or been issued a U.S. Passport Book or Passport Card?
Name as printed on your most recent passport book
Yes No If yes, complete the rema ining items in #21.
PLEASE DO NOT WRITE BELOW THIS LINE - FOR ISSUING OFFICE ONLY
Name as it appears on citizenship evidence
Birth Certificate SR CR City F iled: Issued:
Passport C/R S/R Per PIERS #/DOI:
Attached:
* DS 11 C 09 2013 2 *
P/C of ID
DS-5520DS-3053 DS-64 DS-5513
Citz W/S
DS-10
DS-71
DS-86
IRL CIS Ver
20. 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/Unit
City State Zip Code Phone Number Relationship
DS-11 09-2013
Page 2 of 2
Date of Birth (mm/dd/yyyy)Name of Applicant (Last, First, & Middle)
Name as printed on your most recent passport card
-
-
Mother/Father/Parent - First & Middle Name
Last Name (at Parent's Birth)
Date of Birth (mm/dd/yyyy) Place of Birth
Male
Female
Yes
No
U.S. Citizen?Sex
-
-
--
Report of Birth Filed/Place:
Nat. / Citz. Cert. USCIS USDC Date/Place Acquired: A#
Other:
If yes, complete the remaining items in #11.
Date of Marriage
(mm/dd/yyyy)
11. Have you ever been married?
Full Name of Current Spouse or Most Recent Spouse Date of Birth (mm/dd/yyyy)
Have you ever been widowed or divorced?
Place of Birth
Yes
No
Widow/Divorce Date
(mm/dd/yyyy)
Yes No
Yes
No
U.S. Citizen?
- -
15. Height 16. Ha i r Color 17. Eye Color
Status of your most recent passport book:
Submitting with application
Stolen Lost In my possession (if expired)
Status of your most recent passport card:
Submitting with application
Stolen
Lost
In my possession (if expired)
Most recent passport book number Most recent passport book issue date (mm/dd/yyyy)
Most recent passport card number Most recent passport card issue date (m m/dd/yyyy)
P/C of Citz
