Palau Passport Office Passport Application Page 2
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1
2PALAU PASSPORT OFFICE
Ministry of State, Republic of Palau
See Reverse for Instructions – EXECUTE IN ORIGINAL ONLY
Type of Passport Requested
Regular
Official
Diplomatic
Type or Print in Ink – APPLICATION MUST BE NOTARIZED
FOR OFFICIAL OR DIPLOMATIC APPLICANTS ONLY
FULL NAME:
LAST
Official Title
FIRST
Duty Station
MIDDLE
Office Address
Mailing Adress: Post Office Box Number, Street, City, State, Zip Code
Home Telephone Number
Work Telephone Number
IDENTIFYING INFORMATION
Email Address:
Height
feet
inches
Social Security No.
Sex
Color of Hair
Color of Eyes
Distinguishing Marks or Features
Place of Birth
Date of Birth
□
□
Yes
No
Father’s Name
Place of Birth
Date of Birth
Palauan Citizen
□
□
Yes
No
Mother’s Name
Place of Birth
Date of Birth
Palauan Citizen
MARRIAGE INFORMATION
□
□
□
□
Have you ever been married?
Yes
No
DIVORCED/ WIDOWED?
Yes
No
If yes, give date of most recent marriage
If yes, give date of most recent divorce/death
Spouse’s Full Birth Name
Former Spouse’s Full Birth Name
IN CASE OF EMERGENCY, NOTIFY (Person indicated will never travel with you)
(
)
Full Name
Relationship
Telephone Number
Permanent and Mailing Address
PREVIOUS PASSPORT INFORMATION
□
□
Disposition: Submitted
Lost
Mutilated
Stolen/Burned
Have you ever been issued or included in a Republic of Palau Passport?
Yes
No
Note: If passport is lost, mutilated, stolen or burned submit
with affidavit, also for stolen or burned passports, police
Name in which issued
Passport Number
Issuance Date
report required.
DO NOT SIGN APPLICATION UNTIL REQUESTED TO DO SO BY AN AUTHORIZED OATH-ADMINISTERING OFFICIAL
OATH AND SIGNATURE: I have not, since acquiring Palau citizenship, been naturalized as a citizen of a foreign state other than the United States; taken oath, or
made affirmation or other formal declaration of allegiance to a foreign state (other than the United States); accepted or performed the duties of any office, post, or
employment under the Government of a foreign state or political subdivision thereof (other than the United States); made a formal renunciation of nationality. I disclaim
nationality in any state or country other than the Republic of Palau and the United States, that may have accrued to me through the nationality of my parents or for any
reason whatsoever and I hereby renounce absolutely and entirely all allegiance and fidelity to any foreign province, state or sovereignty other than the United States. I
do not hold any passport or other form of travel document issued to me any foreign state or sovereign, except for the United States.
DECLARATION: I declare that the statements made in this application are true and complete to the best of my knowledge and belief, that the attached photographs
are a true likeness of me.
Signature of Applicant SIGN INSIDE THIS BOX
|
|
2” x 2” PHOTO
Month
Day
Year
GLUE HERE
Date:____________________________
□
AUTHORIZED OATH – ADMINISTERING OFFICIAL
Clerk of Court
□
Passport Agent
□
Notary Public
SEAL
□
Palau Consular Serv.; Location/Title
FOR PASSPORT SERVICES USE ONLY
DO NOT WRITE BELOW THIS SPACE
DO NOT WRITE BELOW THIS
□
□
□
○
○
○
Birth Certificate
Marriage Certificate
Previous Passport
Court Decree
Naturalization
Adoption
□
○
○
○
Affidavit
Lost Passport
Mutilated
Stolen/Burned
Others:________________________
□
Passport Cancelled & Returned
OTH:_____________________________________________________________
□Attached:
BC
MC
CD
OTH:_________________________________________________
APPLICATION APPROVAL
○
○
○
○
REGULAR
OFFICIAL
DIPLOMATIC
RENEWAL
PASSPORT NUMBER: ______________________
ISSUANCE DATE:__________________________
EXPIRATION DATE:_______________________
Receipt No. ____________________
Date paid: _____________________
Issued by: __________/___________
Entered: _______________________
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