Machine Readable Passport Application

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FOREIGN SERVICE OF THE PHILIPPINES
PHILIPPINE CONSULATE GENERAL
30 N. Michigan Avenue, Suite 2100, Chicago, IL 60602
Tel No. (312) 332-6458
Fax No. (312) 332-3657
Website:
MACHINE READABLE PASSPORT APPLICATION
PLEASE PROVIDE CORRECT INFORMATION AND DO NOT LEAVE SPACES OR BLANKS.
_______________________________________________
LAST NAME/ APELYIDO
Paste one
4.5 cm X
_______________________________________________
__________________________________________
3.5cm
FIRST NAME/ PANGALAN (Jr./ II/ III)
DATE OF BIRTH (Ex. 01-January-2000)
new colored
PETSA NG KAPANGANAKAN
photo
with ROYAL
BLUE
_______________________________________________
_________________________________________
background
MIDDLE NAME/ GITNANG PANGALAN
PLACE OF BIRTH/ POOK NG KAPANGANAKAN
GENDER/ KASARIAN
[
] Male
[
] Female
Civil Status: [
] Single
[
] Married
[
] Widow/er
[
] Divorced
Name of Wife/ Husband: ______________________________________________________ Citizenship: _________________
First Name
Middle Name
Last Name
Complete Address: ____________________________________________________________________ Tel. No.: ___________________
Present Occupation _________________________ Country of Destination ________________________ Mobile No. _________________
Office of Employment _____________________________ E-mail address _________________________ Tel. No. ___________________
Name of Father _______________________________________________________________________ Citizenship _________________
(AT THE TIME OF APPLICANT'S BIRTH)
First Name
Middle Name
Last Name
Maiden/ Single Name of Mother __________________________________________________________ Citizenship __________________
(AT THE TIME OF APPLICANT'S BIRTH)
First Name
Middle Name
Last Name
Citizenship acquired by : [
] Birth
[
] Election
[
] Marriage
U.S. Visa: [
] Tourist
[
] Seaman
[
] Business
[
] Naturalization
[
] R. A. 9225
[
] Others ________________
[
] Immigrant
[
] Study
[
] Work
[
] Others _______________
Are you a holder of a foreign passport? [
] Yes
[
] No
Have you ever been issued a Philippine Passport? [
] Yes
[
] No
If Yes, Latest Passport No. ________________________________________
If Yes, from what country? ___________________________________
Date of Issue: _____________________ Place of Issue; _________________
This serves as Affidavit of Support and Consent to Travel
This serves as Affidavit of Loss
(for applicants below 18 years old ONLY)
Lost Passport No.: _______________________________________________
Name of Minor’s traveling companion: ______________________________
Issued on: __________________ Issued by: _________________________
Companion’s Relationship: _______________________________________
Date Lost: _____________________________________________________
Address/ Contact No.: __________________________________________
Lost due to: ____________________________________________________
__________________________________________
____________________________________
Signature of Parent or Legal Guardian
Signature of Applicant
I SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided in this application is true and correct. 3) The supporting documents attached are authentic.
4) I have nor been issued a passport under any other name. 5) The attached photograph is mine. 6) I am aware that under the law, I am allowed to hold only one Philippine passport at any
given time. 7) I am aware that making false statements in passport application, furnishing falsified or forged documents in support thereof are punishable by law.
___________________________________________________________________
SIGNATURE OF APPLICANT
Take care not to perforate the photograph
REMARKS:
Place
two(2)
Photo
In a
pouch
then
staple
here
Left
Right
Thumb Mark
Thumb Mark
FOR STRICT COMPLIANCE: Please print name and affix initials
Processor ____________________________________
Encoder _____________________________________ Signing Officer _______________________________________
RECEIVED CANCELLED PASSPORT:
RECEIVED NEW PASSPORT:

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