Form 6 Declaration Of Lost, Stolen Or Mutilated Belize Passport

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Form 6
Regulation 7(4)
DECLARATION OF LOST, STOLEN OR MUTILATED BELIZE PASSPORT
WARNING TO ALL APPLICANTS
Any such person who makes a written or oral statement knowingly to be false
Or misleading is guilty of an offence and is liable to fine and Imprisonment
PLEASE PRINT INFORMATION IN BLOCK LETTERS
FOR OFFICIAL USE ONLY
USING DARK BLUE OR BLACK INK PEN
PASSPORT CONTROL OFFICER
THIS FORM IS TO BE FILLED OUT BY THE APPLICANT & SHOULD BE SIGNED IN THE
PRESENCE OF THE COMMISSION OF AFFIDAVITS, JUSTICE OF THE PEACE OR NOTARY PUBLIC
This is to report the loss, theft or mutilation of a Belize passport IMPORTANT: Completing this form will not provide you with
a replacement passport. To replace your lost, stolen or mutilated passport, you will need to submit this form, one passport
sized photograph, a passport application form, supporting documents and fee
1.
DETAILS OF THE LOST/STOLEN OR MUTILATED PASSPORT
NAMES IN WHICH THE PASSPORT WAS ISSUED
SURNAME
/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
FIRST NAME
__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/__
MIDDLE NAME(S) / _/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
DATE OF BIRTH
___/___
___/___/___
___/___/___
Date
Month
Year
TOWN/ CITY OF
BIRTH/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/__/___/___/___/___/___/___/___/___/___/___/___/___/__
COUNTRY OF BIRTH /___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/__
PASSPORT NO.
/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
DATE OF ISSUE
___/___
___/___
___/___/___/___
Date
Month
Year
ISSUE OFFICE
/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/_/
/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
STATUS OF PASSPORT
LOST
STOLEN
MUTILATED
2.
CURRENT DETAILS (TO BE FILLED ONLY IF DIFFERENT FROM SECTION 1)
CURRENT
SURNAME/___/___/___/___/___/___/___/___/___/___/____/___/___/___/____/___/___/___/___/___/___/___/___/___/___/___/__/
CURRENT FIRST
NAME/___/___/___/___/__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
CURRENT MIDDLE NAMES(S)
/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
3.
CURRENT HOME ADDRESS
/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
/___/___/___/___/___/___/___/___/___/___/___/___/___/___/_HOME TEL. NO__/___/___/___/___/___/___/___/___/___/___/___/ E-MAIL
ADDRESS___________________________________ MOBILE NO. /___/___/___/___/___/___/___/___/___/___/___/___/

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