Name of Applicant (Last, First, & Middle)
Date of Birth (mm/dd/yyyy)
10. Parental Information
Last Name (at Parent's Birth)
Mother/Father/Parent - First & Middle Name
Date of Birth (mm/dd/yyyy)
Place of Birth
Sex
U.S. Citizen?
-
-
Male
Yes
Female
No
Mother/Father/Parent - First & Middle Name
Last Name (at Parent's Birth)
Date of Birth (mm/dd/yyyy)
Place of Birth
Sex
U.S. Citizen?
-
-
Male
Yes
Female
No
11. Have you ever been married?
Yes
No
If yes, complete the remaining items in #11.
Place of Birth
Full Name of Current Spouse or Most Recent Spouse
Date of Birth (mm/dd/yyyy)
-
-
Date of Marriage
U.S. Citizen?
Have you ever been widowed or divorced?
Widow/Divorce Date
(mm/dd/yyyy)
No
No
Yes
(mm/dd/yyyy)
Yes
12. Additional Contact Phone Number
13. Occupation (if age 16 or older)
14. Employer or School (if applicable)
Home
Cell
-
-
Work
18. Travel Plans
15. Height
16. Hair Color
17. Eye Color
Countries to be Visited
Departure Date (mm/dd/yyyy)
Return Date (mm/dd/yyyy)
19. Permanent Address - If P.O. Box is listed under Mailing Address or if residence is different from Mailing Address.
Street/RFD # or URB (No P.O. Box)
Apartment/Unit
City
State
Zip Code
20. Emergency Contact - Provide the information of a person not traveling with you to be contacted in the event of an emergency.
Address: Street/RFD # or P.O. Box
Apartment/Unit
Name
City
State
Zip Code
Phone Number
Relationship
21. Have you ever applied for or been issued a U.S. Passport Book or Passport Card?
Yes
No
If yes, complete the remaining items in #21.
Name as printed on your most recent passport book
Most recent passport book number Most recent passport book issue date
(mm/dd/yyyy)
Stolen
Lost
In my possession (if expired)
Status of your most recent passport book:
Submitting with application
Name as printed on your most recent passport card
Most recent passport card number Most recent passport card issue date
(mm/dd/yyyy)
Status of your most recent passport card:
Submitting with application
Stolen
Lost
In my possession (if expired)
PLEASE DO NOT WRITE BELOW THIS LINE - FOR ISSUING OFFICE ONLY
Name as it appears on citizenship evidence
Birth Certificate
SR
CR
City
Filed:
Issued:
Nat. / Citz. Cert. USCIS USDC Date/Place Acquired:
A#
Report of Birth
Filed/Place:
Passport
C/R
S/R
Per PIERS
#/DOI:
Other:
Attached:
P/C of ID
DS-3053
DS-64
DS-5520
DS-5513
Citz W/S
* DS 11 C 09 2013 2 *
P/C of Citz
DS-10
DS-86
DS-71
IRL
CIS Ver
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09-2013
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