Form Ds-4085 - Application For Additional Visa Pages Page 4
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4APPLICATION FOR ADDITIONAL VISA PAGES
OMB APPROVAL NO. 1405-0159
OR MISCELLANEOUS PASSPORT SERVICES
EXPIRATION DATE: 12-31-2010
ESTIMATED BURDEN: 20 MIN
WARNING: False statements made knowingly and willfully in passport applications, including
affidavits or other documents submitted to support this application, are punishable by fine
and/or imprisonment under the provisions of 18 USC 1001, 18 USC 1542, and/or 18 USC 1621.
Alteration or mutilation of a passport issued pursuant to this application is punishable by fine
and/or imprisonment under the provisions of 18 USC 1543. The use of a passport in violation
of the restrictions contained therein or of the passport regulations is punishable by fine and/or
imprisonment under 18 USC 1544. All statements and documents are subject to verification.
1. Name Last
2. Date of Birth (mm/dd/yyyy)
First & Middle
-
-
4. Place of Birth (City & State or City & Country as it is presently known)
5. Social Security Number
3. Sex
-
-
M
F
6. Mailing Address: Street/RFD # or P.O. Box
Apartment or unit #
City
State
Zip Code (Zip + 4 if known)
In Care Of or Country, if applicable
7. Contact Phone Number
8. Email Address (Optional)
Home
Cell
-
-
Work
9. Current Passport Number
10. Permanent Address: Street/RFD # (No P.O. Box)
Apartment or unit #
Issue date (mm/dd/yyyy)
City
State
Zip Code
11. Additional Contact Phone Number
12. Occupation
13. Employer
Home
Cell
Work
_________
14. 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 or unit #
City
Zip Code
Phone Number
City
State
Relationship
15. Travel Plans
Date of Trip (mm/dd/yyyy)
Length of Trip
Countries to be visited
YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW
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 the reverse side 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.
This section for
x ____________________________________________________
issuing office only
Applicant’s Signature - age 16 and older
x ____________________________________________________
Parent’s/Legal Guardian’s Signature (if identifying minor)
_________________________________________________
Date
EF________
Postage________
Other________
DS-4085 02-2010
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