1
TALOSAGA MO TUSIFOLAU SAMOA
APPLICATION FOR SAMOAN PASSPORT
FA’AMOLEMOLE FAITAU MUAMUA IA MĀLAMALAMA I FA’ATONUGA (ITULAU 3)
Government of Samoa
ONA FA’ATUMU AI LEA O LE TALOSAGA.
Please read the instructions on (page 4) BEFORE you complete this form in ink
FA’AMATALAGA O LĒ O LO’O TALOSAGA
VAEGA A.
APPLICANT’S DETAILS
SECTION A.
2. Fa’aiu:
1. Ou igoa Fa’atulafonoina:
Given Name/s:
Last Name:
3. Ou Suafa Matai (tau’a’ao mai pepa matai):
Title names (attach title certificates)
4. Isi igoa e te Agava’a ai (Fa’ataitaiga: Suafa matai o lou tamā):
Other names you are entitled to use (Example: father’s Title etc):
5. Fa’aiu ae le’i fa’aipoipo pe ā fai o se tama’ita’i? (tau’a’ao mai lau pepa fa’aipoipo)
If married, what is your maiden name? (attach your marriage certificate)
ASO
M
T
6. Aso Fānau:
7. Maualuga
8. Lanu o Mata:
Date of Birth:
Height:
Ft.
In.
Colour of Eyes:
DAY
MTH
YR
9. Nu’u ma le atunu’u na fanau ai:
10. Galuega:
Place & Country of Birth:
Occupation:
A fai e te le’i fanau i Samoa, fa’apipi’i mai lou pepa sitiseni po o pepa talafeagai (pepa fānau Samoa a ou matuā)
If not born in Samoa, attach evidence of Citizenship (parents Samoan Birth Certificate, Citizenship Certificate, etc)
Fa’ailoga mai le pusa e te agava’a ai.
Please tick the appropriate box.
11. Fa’aipoipoga:
Le’i Fa’aipoipo
Fa’aipoipo
Maliu le To’alua
Tēte’a
Marital Status:
Single
Married
Divorced
Widowed
12. Ali’i po’o le tama’ta’i: Tama’ita’i
Ali’i
Gender:
Female
Male
Nofoaga/tuatusi o lo’o E aumau ai:
13.
Current Full Address:
14. Numera Telefoni:
(ofisa)
(fale)
imeli
Telephone Number: (work)
(home)
email
15. Na E umia muamua se Tusifolau po o se Pepa Malaga ? Ioe
Leai
Have you previously been issued a Passport or CI?
Yes
No
16. Afai sa i ai – aso na tuuina atu ai?
- Numera
Issue date of most recent passport?
- Number
(Faamolemole – Tau’a’ao mai - Afai ua leiloa, tau’a’ao mai se fa’amaoniga - Ripoti mai le Ofisa o Leoleo)
(Please attach previous travel document or Police Report if lost.)
TA’UTINOGA:
Ou te ta’utino atu o tali ma fa’amatalaga uma ua ou tu’uina atu i luga e moni i itū uma, ma, ua uma fo’i ona ou
faitauina ma malamalama i aiaiga o le tulafono e pei ona iai i le numera 8 o FA’ATONUGA.
DECLARATION:
I hereby declare that all the answers and information given by me above are true in every respect and I have also
read and understood the law as quoted in number 8 of INSTRUCTIONS.
ASO
M
T
Saini
Aso:
Signature:
Date:
DAY
MTH
YR