U.s. Passport Renewal From Canada By Appointment Order Form, Form Ds11 - Application For A Us Passport From Canada Page 2
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1
2
3APPLICATION FOR A U.S. PASSPORT
OMB CONTROL NO. 1405-0004
OMB EXPIRATION DATE: 01-31-2017
Please Print Legibly Using Black Ink Only
ESTIMATED BURDEN: 95 MIN
Attention: Read WARNING on page 1 of instructions
Please select the document(s) for which you are applying:
U.S. Passport Book
Both
U.S. Passport Card
The U.S. passport card is not valid for international air travel. For more information see page 1 of instructions.
28 Page Book (Standard)
52 Page Book (Non-Standard)
Note: The 52 page option is for those who frequently travel abroad during the passport validity period, and is recommended
for applicants who have previously required the addition of visa pages.
1. Name Last
D
DOTS
O
Dep
End. #
Exp.
First
Middle
2. Date of Birth (mm/dd/yyyy)
4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.)
3. Sex
M
F
-
-
6. Email Address (e.g., )
5. Social Security Number
7. Primary Contact Phone Number
-
-
-
-
@
8. Mailing Address: Line 1: Street/RFD#, P.O. Box, or URB.
Address Line 2: Clearly label Apartment, Company, Suite, Unit, Building, Floor, In Care Of or Attention if applicable. (e.g., In Care Of - Jane Doe, Apt # 100)
City
State
Zip Code
Country, if outside the United States
9. List all other names you have used. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed)
A.
B.
STOP! CONTINUE TO PAGE 2
DO NOT SIGN APPLICATION UNTIL REQUESTED TO DO SO BY AUTHORIZED AGENT
Identifying Documents - Applicant or Mother/Father/Parent on Second Signature Line (if identifying minor)
Driver's License
State Issued ID Card
Passport
Military
Other
Name
Issue Date
Exp. Date
State of
(mm/dd/yyyy)
(mm/dd/yyyy)
Issuance
Country of
ID No
Issuance
Identifying Documents - Applicant or Mother/Father/Parent on Third Signature Line (if identifying minor)
State Issued ID Card
Driver's License
Passport
Military
Other
Attach a color photograph
taken within the last six months
Name
Issue Date
Exp. Date
State of
Acceptance Agent
(Vice) Consul USA
(mm/dd/yyyy)
(mm/dd/yyyy)
Issuance
Passport Staff Agent
Country of
ID No
Issuance
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
page four of the instructions of this application (unless explanatory statement is attached); 2) the statements made on the
(Seal)
application are true and correct; 3) I have not knowingly and willfully made false statements or included false documents
in support of this application; 4) the photograph attached to this application is a genuine, current photograph of me; and
5) I have read and understood the warning on page one of the instructions to the application form.
x
Applicant's Legal Signature - age 16 and older
Name of courier company (if applicable)
Facility ID Number
x
Mother/Father/Parent/Legal Guardian's Signature (if identifying minor)
Facility Name/Location
Agent ID Number
x
Mother/Father/Parent/Legal Guardian's Signature (if identifying minor)
Signature of person authorized to accept applications
Date
Bk
Card
* DS 11 C 09 2013 1 *
For Issuing Office Only
EF
Postage
Execution
Other
DS-11
09-2013
Page 1 of 2
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