Form Ds-11 - Application For A Us Passport Page 5
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6US DEPARTMENT OF STATE
OMB APPROVAL NO. 1405-0004
EXPIRATION DATE 06/30/2005
APPLICATION FOR A US PASSPORT
ESTIMATED BURDEN: See Instruction Page 3
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 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
5 Yr.
10 Yr.
Issue
documents are subject to verification.
Date
R
D
O
DP
1. Name of Applicant
Last
Suffix (Jr., Sr., III)
End. #
Exp.
2. Date of Birth (mm/dd/yyyy)
First
Middle
6. Alien Registration No.
5. Social Security Number
4. Place of Birth
3. Sex
(If applicable)
(See Federal Tax Law Notice on Instruction Page 3)
(City & State OR City & Country)
M
F
7. Height
8. Hair Color
9. Eye Color
10. Occupation
11. Employer
Feet
Inches
12. E-Mail Address
13. Mailing Address
(Optional)
Street / RFD # OR Post Office Box
Apartment #
City
State
Zip Code
Country
In Care of
(If outside the US)
(if applicable)
14. 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,
15. Home Telephone
16. Business Telephone
color photographs
(Include Area Code)
(Include Area Code)
(
)
(
)
17. Have you ever applied for or been issued a
If yes, complete the remaining items in block #17 and submit
YES
NO
US passport?
most recent passport.
Name in which your most recent passport was issued.
Status of most recent passport.
Submitted
Stolen
Lost
Other___________________
Approximate date your most recent US
Most recent passport number.
passport was issued or date you applied.
18. Travel Plans
Date of Trip
Length of Trip
Countries to be Visited
(mm/dd/yyyy)
If yes, complete the remaining items in block #19.
19. Have you ever been married? YES
NO
Spouse’s or Former Spouse’s Full Name
Is your spouse (or former spouse) a US citizen?
YES
NO
Date of Birth
Place of Birth
Date of Most
Widowed?
Divorced?
Recent Marriage
Give Date:
20. What other names have you used?
(Include name changes, maiden name, & former married names)
1)
2)
3)
4)
DS-11
Page 1 of 2
11/2004
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