Embassy Of Ethiopia - Renew/lost/damage Ethiopian Origin Id Request Form

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bTWLD xþT×eÃêE m¬wqE Ã µRD

EMBASSY OF ETHIOPIA

3506 INTERNATIONAL DR NW

CONSULAR OFFICE

XDúT/b«Í MTK/btb§¹ MTK m«yqE Ã QA

WASHINGTON DC 20008

PASSPORT AND VISA SERVICES

TELE (202) 364 1200

RENEW/LOST/DAMAGE ETHIOPIAN ORIGIN ID REQUEST FORM

XDúT

b«Í MTK

btb§¹ MTK

RENEW

LOST

DAMAGE

PLEASE TYPE OR PRINT YOUR ANSWER IN THE SPACE PROVIDED BELOW EACH ITEM, FOR INSTRUCTION SEE THE REVERSE SIDE OF THIS FORM

1. TITLE/PREFIX

2. FIRST NAME

3. MIDDLE/FATHER NAME

4. GRAND FATHER NAME

5. SEX

6. OCCUPATION

7. HEIGHT

8. COLOR OF EYES

9. COLOR OF HAIR

10. SPECIAL MARK

11. COUNTRY OF BIRTH

12. PLACE OF BIRTH

13. NATIONALITY AT BIRTH

14. CURRENT NATIONALITY

15. MAILING ADDRESS

16. COUNTRY

17. STATE/REGION

18. CITY

19. ZIP CODE

20. DAYTIME TEL

21. EVENING TEL

22. FAX

23. EMAIL

24. DOMICILE/COUNTRY OF RESIDENCE

DON NOT WRITE IN THIS SPACE

PASSPORT AND ORIGIN ID INFORMATION

FOR OFFICIAL USE ONLY

PASSPORT INFORMATION

PREVIOUS ETHIOPIAN ORIGIN ID

RENEWAL NUMBER

(CURRENT NATIONALITY)

INFORMATION

________________________________________

25.

PASSPORT NUMBER

26.

ETHIOPIAN ORIGIN ID NUMBER

RENEWED DATE ________________________

25.

DATE OF ISSUE

25.

VALID UNTIL

26.

DATE OF ISSUE

26.

VALID UNTIL

VALID UNTIL____________________________

25.

PLACE OF ISSUE

26.

PLACE OF ISSUE

GRATIS

YES

25.

ISSUING COUNTRY

26.

ISSUING COUNTRY

[

FEE PAID_______________________________

RECEIPT NO____________________________

I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

APPLICANT’S NAME: ___________________________________________________________________ SIGNATURE:______________________________ DATE: _____________________________

IF THIS APPLICATION HAS BEEN PREPARED BY A TRAVEL AGENCY OR OTHER PERSON ON YOUR BEHALF, THE AGENT SHOULD INDICATED THE NAME OF THE AGENCY OR PERSON,

WITH APPROPRIATE SIGNATURE OF THE INDIVIDUAL PREPARED THIS FORM

NAME OF PERSON WHO PREPARED THIS FORM : __________________________________________ SIGNATURE :______________________________ DATE: _____________________________