Form Ds-11 - Family Guardian Page 3
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4U.S. Department of State
APPLICATION FOR
U.S. PASSPORT
REGISTRATION
(Type or print all capital letters in blue or black ink in white areas only)
1. NAME (First and Middle)
LAST
2. MAIL PASSPORT TO: STREET / RFD # OR P.O. BOX
APT. #
5 Yr.
10 Yr.
Issue
Date
R
D
DP
CITY
STATE
O
End. #
Exp.
ZIP CODE
COUNTRY / IN CARE OF (if applicable)
6. SOCIAL SECURITY NUMBER
5. DATE OF BIRTH
4. PLACE OF BIRTH
3. SEX
(City & State or City & Country)
Year
Month
Day
(SEE FEDERAL TAX LAW NOTICE ON PAGE 4)
M
F
7. HEIGHT
8. HAIR COLOR
9. EYE COLOR
10. HOME TELEPHONE
11. BUSINESS TELEPHONE
12. OCCUPATION
Feet
Inches
13. PERMANENT ADDRESS (DO NOT LIST P.O. BOX) Street/R.F.D.#
City
State
U.S. CITIZEN
U.S. CITIZEN
14. FATHER'S FULL NAME
BIRTHPLACE
BIRTHDATE
15. MOTHER'S FULL MAIDEN NAME
BIRTHDATE
BIRTHPLACE
Last
First
Last
First
Yes
Yes
No
No
16. HAVE YOU EVER
U.S. CITIZEN
SPOUSE'S OR FORMER SPOUSE'S FULL NAME AT BIRTH
BIRTHPLACE
BIRTHDATE
BEEN MARRIED?
Yes
Yes
No
No
DATE OF MOST RECENT MARRIAGE WIDOWED/DIVORCED?
17. OTHER NAMES YOU HAVE USED
Month
Day
Year
Month Day
Year
Yes
Give Date
(1)
(2)
No
18. HAVE YOU EVER BEEN ISSUED A U.S. PASSPORT?
IF YES, COMPLETE NEXT LINE AND SUBMIT PASSPORT IF AVAILABLE.
DISPOSITION
Yes
No
APPROXIMATE ISSUE DATE
NAME IN WHICH ISSUED
Submitted
Stolen
MOST RECENT PASSPORT NUMBER
Month
Day
Year
Lost
Other
It is necessary to submit a statement with an application for a new passport when a previous valid or potentially valid passport cannot be presented.
The statement must set forth in detail why the previous passport cannot be presented. Use Form DS-64.
S
S
T
T
19. EMERGENCY CONTACT. If you wish, you may supply the name, address and telephone number of a
20. TRAVEL PLANS (not mandatory)
A
A
person not traveling with you to be contacted in case of emergency.
Month
Day
Year
P
P
Date
L
L
NAME
of Trip
E
E
Length
of Trip
STREET
COUNTRIES TO BE VISITED:
CITY
STATE
ZIP CODE
TELEPHONE
S
S
STOP.
DO NOT SIGN APPLICATION UNTIL REQUESTED TO DO SO BY PERSON ADMINISTERING OATH.
T
21.
T
A
A
I have not, since acquiring United States citizenship, performed any of the acts listed under "Acts or Conditions" on the reverse of
P
P
this application form (unless explanatory statement is attached). I solemnly swear (or affirm) that the statements made on this
L
L
SUBMIT TWO RECENT
E
E
application are true and the photograph attached is a true likeness of me.
IDENTICAL PHOTOS
X
Father's/Legal Guardian's Signature (if identifying minor)
X
Applicant's Signature - age 14 or older
X
Mother's/Legal Guardian's Signature (if identifying minor)
22. FOR ACCEPTANCE AGENT'S USE
Clerk of Court; Location
Subscribed and sworn to (affirmed) before me
Month
Day
Year
PASSPORT Agent
Postal Employee
(Signature of person authorized to accept application)
(Vice) Consul USA
23a. Applicant's or Father's Identifying Documents
23b. Mother's Identifying Documents
Passport
Other (Specify)
Passport
Other (Specify)
Driver's License
Driver's License
Issue
Expiration
Place of
Issue
Expiration
Place of
:
:
Date
Date:
Issue:
Date
Date:
Issue:
Name
ID No.
Name
ID No.
24. FOR ISSUING OFFICE USE ONLY (Applicant's evidence of citizenship)
Birth Certificate
SR
CR
City
Filed/Issued:
Passport Bearer's Name:
Report of Birth:
Naturalization/Citizenship Cert. No:
Issued:
Other:
Seen & Returned:
APPLICATION APPROVAL
Attached:
25.
FEE
EXEC.
EF
OTHER
DS-11
OMB No. 1405-0004 Expires: 03/31/2005 Estimated Burden - 20 Minutes
Page 3 of 4
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