Us Passport Re-Application Form
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2OMB APROVAL NO. 1405-0160
U.S. DEPARTMENT OF STATE
EXPIRES: 08/31/2008
ESTIMATED BURDEN: See Instruction Page 3
U.S. PASSPORT RE-APPLICATION FORM
WARNING:
False statements made knowingly and willfully in passport applications including affidavits or other
supporting documents submitted therewith, are punishable by fine and/or imprisonment under the provisions of 18 U.S.C.
1001, 18 U.S.C. 1542, and/or 18 U.S.C. 1621. Alteration or mutilation of a passport issued pursuant to this application is
punishable by fine and/or imprisonment under the provisions of 18 U.S.C. 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 U.S.C.
1544. All statements and documents are subject to verification.
When completing this form, PRINT IN BLUE OR BLACK INK ONLY.
5 Yr.
10 Yr.
Issue
Date
1. Name of Applicant
R
D
O
DP
Last
Suffix
(Jr., Sr., III)
End. #
Exp.
First
Middle
2. Date of Birth
3. Sex
Place of Birth
5. Social Security Number
4.
(mm/dd/yyyy)
(City & State OR City & Country)
(See Federal Tax Law Notice on Instruction Page 3.)
M
F
6. Height
7. Hair Color
8. Eye Color
9. Occupation
10. Employer
Feet
Inches
12. Mailing Address
11. E-Mail Address
(Optional)
Street / RFD # OR Post Office Box
Apartment #
ZIP Code
City
State
Country
In Care of
(If outside the U.S.)
(if applicable)
13. Permanent Address or Residence
(If same as mailing address write “Same As Above”)
Street / RFD #
Apartment #
(DO NOT LIST P.O. BOX)
City
State
ZIP Code
Submit two recent,
14. Home Telephone
15. Business Telephone
(Include Area Code)
(Include Area Code)
color photographs
(
)
(
)
16. Emergency Contact—
Provide the information of a person not traveling with you to be contacted in the event of an emergency.
Name
Street / RFD #
Apartment #
ZIP Code
City
State
Telephone
(
)
E-mail Address
Relationship
(Optional)
17. Travel Plans
Date of Trip
Length of Trip
Countries to be Visited
(mm/dd/yyyy)
18. Current U.S. Passport Information
TO USE THIS FORM, YOUR CURRENT PASSPORT MUST BE LESS THAN ONE YEAR OLD.
Date your most recent U.S. passport was issued
Name—As printed in your most recent U.S. passport
(mm/dd/yyyy)
Place your most recent U.S. passport was issued
Most Recent U.S. Passport Number
(Passport must be submitted with this application)
DS-5504
Page 1 of 2
08/2005
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