Form 5001a - Fsm Passport Application Form Page 3
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4FSM FORM 5001B-REVISED FORM 5001A
FSM PASSPORT APPLICATION FORM
Applicant Photo
FOR OFFICIAL USE ONLY
Applicant must complete this form and forward it to the
Division of Immigration & Labor, Department of Justice,
Document Issued On: ______________
FSM National Government, Palikir, Pohnpei FM 96941
1 3/16 x 1 ¾
Issuing Official:___________________
PLEASE FOLLOW INSTRUCTIONS
Type of Passport: [ ] Ordinary [ ] Official [ ] Diplomatic
Applicant Information
Name: __________________________________
______________________
______________________________________
Last Name
Middle Initial
First Name
Other Names You Have Used:__________________________________________________________________________________
Date of Birth: ____________________ Gender
[ ] Miss
[ ] Mrs.
[ ] Ms.
[ ] Mr.
Height: ________________ Feet _____________Inches
Hair Color___________ Eye Color ___________
Birth Place: ______________________________ Home Address:_______________________________________________________
Current Postal Address:_________________________________________________________________________________________
Have you ever been issued a foreign passport: [ ] Yes [ ] No
If yes, country of issuance, date issued and passport number____________________________________________________________
Basis of FSM citizen: [ ] Birth [ ] Naturalization [ ] Other means (Provide prove)
Father Information
Last Name:_________________________ First Name:_____________________________ Middle Name: ______________________
Birthdate:_________________________ Birthplace:_________________________ Is your father FSM citizen? [ ] Yes [ ] No
If no what nationality:________________________
Mother Information
Last Name:__________________________ First Name:_____________________________ Middle Name:______________________
Birthdate:_________________________ Birthplace:________________________ Is your mother FSM citizen? [ ] Yes [ ] No
If no what nationality:_____________________
Signature of Applicant Required (Do not sign in the box for infant and adult who cannot
Sign)
Please sign within the box. Signature must not touch line.
Signature of parent or guardian if under age 14 or unable to sign application._____________________________________________________________________
Subscribed and sworn to before me this ____________day of ______________ 20
S E A L
I hereby certify that I reviewed the application and found to be complete and I am satisfied that the applicant is a citizen of the Federated States of Micronesia, and
that he/she does not owe allegiance to any foreign country.
____________________________________
Reviewing Officer
_________________________
Date
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