Form Ds-11 - Application For A Us Passport Page 6
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6NAME OF APPLICANT
Date of Birth
(Last, First, Middle)
(mm/dd/yyyy)
21. Parental Information
Mother’s Maiden Name
Date of Birth
Place of Birth
Last
First
Middle
Father’s Name
Date of Birth
Place of Birth
Last
First
Middle
Is your mother a US citizen?
Is your father a US citizen?
YES
NO
YES
NO
22. 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 #
City
State
Zip Code
Telephone
(
)
E-mail Address
Relationship
(Optional)
STOP!
DO NOT SIGN APPLICATION UNTIL REQUESTED TO DO SO BY PERSON ADMINISTERING OATH.
23. Oath & Signature
I declare under penalty of perjury that I am a United States citizen and have not, since acquiring United States citizenship, performed any of the acts listed
under “Acts or Conditions” on the reverse of this application form (unless explanatory statement is attached). I solemnly swear (or affirm) that the statements
made on this application are true and correct and the photograph attached is a true likeness of me.
Applicant’s or Father’s Identification information
X
Type of Document
Issue Date
Applicant’s Signature—age 14 and older
Driver’s License
Expiration Date
Passport
X
Military Identification
Place of Issue
Mother’s/Legal Guardian’s Signature
(if identifying minor)
Other (Specify)
Name
X
ID Number
Father’s/Legal Guardian’s Signature
(if identifying minor)
Mother’s Identification information
F O R A C C E P T A N C E AG E N T U S E O N L Y
Issue Date
Type of Document
Facility Identification Number
Driver’s License
Expiration Date
Acceptance Agent; Facility Name & Location
Passport
Military Identification
Place of Issue
Other (Specify)
(Vice) Consul USA; Location
Name
ID Number
Passport Services’ Staff Agent
Subscribed & sworn to (affirmed) before me
(SEAL)
Date
(Signature of person authorized to accept applications)
For Issuing Office Use Only
Name as it appears on citizenship evidence:
Birth Certificate:
SR
CR
City
File Date:
Issue Date:
Passport
Issue Date:
Report of Birth:
240 545 1350
Issue Date:
Naturalization Certificate
Issue Date:
Cert. #:
Citizenship Certificate
Issue Date:
Cert. #:
Other:
APPLICATION APPROVAL
Seen & Returned
FEE _________ EXEC. _________ EF _________ OTHER _________
Attached:
DS-11
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