Form Pa-1 - Passport Application Form - Palau Passport Office
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1
2PALAU PASSPORT OFFICE
Ministry of State, Republic of Palau
See Reverse for Instructions
EXECUTE IN ORIGINAL ONLY
Type of Passport Requested
Regular
Official
Diplomatic
–
Type or Print in Ink
- APPLICATION MUST BE NOTORIZED
FULL NAME:
LAST
FOR OFFICIAL OR DIPLOMATIC APPLICANTS ONLY
FIRST
Official Title: _______________________________________
MIDDLE
_______________________________________________________________________________
Duty Station: _______________________________________
Mailing Address: Post Office Box Number, Street, City, State, Zip Code
IDENTIFYING INFORMATION
_____________________________
___________
Height __________feet__________inches
_________________________
_________________________
Social Security No.
Sex
Color of Hair
Color of Eyes
_____________________________________________
__________________________________________
___________________________________________
Distinguishing Marks or Features
Place of Birth
Date of Birth
__________________________ _________________________ □Yes
□No
_______________________________________________________________
Father’s Name
Place of Birth
Date of Birth
Palauan Citizen
__________________________ _________________________ □Yes
□No
_______________________________________________________________
Mother’s Name
Place of Birth
Date of Birth
Palauan Citizen
MARRIAGE INFORMATION
Have you ever been married?
Yes
No
DIVORCED/WIDOWED?
Yes No
If yes, give date of most recent marriage _______________________________ If yes, give date of most recent divorce/death_____________________________
__________________________________________________________________ ___________________________________________________________________
Spouse’s Full Birth Name
Former Spouse’s Full Birth Name
IN CASE OF EMERGENCY, NOTIFY (Person indicated will never travel with you)
__________________________________________________________________ _________________________________
(
)_______________________
Full Name
Relationship
Telephone Number
_______________________________________________________________________________________________________________________________________
Permanent and Mailing addresses
PREVIOUS PASSPORT INFORMATION
Have you ever been issued or included in a Republic of Palau Passport? Yes No
Disposition: Submitted Lost Mutilated Stolen/Burned
Note: If passport is lost, mutilated, stolen or burned submit with
affidavit , also for stolen or burned passports, police report required.
___________________________________ __________________ ___________________
Cancelled & Returned
Attached
Name in which issued
Passport Number
Issuance Date
DO NOT SIGN APPLICATION UNTIL REQUESTED TO DO SO BY AN AUTHORIZED OATH-ADMINISTERING OFFICIAL
OATH AND SIGNATURE:
I have not, since acquiring Palau citizenship, been naturalized as a citizen of a foreign state other than the United States; taken oath, or
made affirmation or other formal declaration of allegiance to a foreign state (other than the United States); accepted or performed the duties of any office, post, or
employment under the Government of a foreign state or political subdivision thereof (other than the United States); made a formal renunciation of nationality. I
disclaim nationality in any state or country other than the Republic of Palau and the United States, that may have accrued to me through the nationality of my parents or
for any other reason whatsoever and I hereby renounce absolutely and entirely all allegiance and fidelity to any foreign province, state or sovereignty other than the
United States. I do not hold any passport or other form of travel document issued to me by any foreign state or sovereign, except for the United States.
DECLARATION:
I declare that the statements made in this application are true and complete to the best of my knowledge and belief, that the attached photographs
are a true likeness of me.
Signature of Applicant:
SIGN INSIDE THIS BOX
Month Day
Year
2”X2” PHOTO
Subscribed and sworn to (affirmed) before me
GLUE HERE
Month Day
Year
________________________________________________
SEAL
AUTHORIZED OATH – ADMINISTERING OFFICIAL
Clerk of Court
Passport Agent
Notary Public
Palau Consular Serv.; Location/Title:
FOR PASSPORT SERVICES USE ONLY
DO NOT WRITE BELOW THIS SPACE
DO NOT WRITE BELOW THIS
Applicants evidence of citizenship
Birth Certificate
Filed/Issued:
Passport
Bearer’s Name:
Report of Birth:
Marriage Certificate
Court Decree:
Name Change
Naturalization
Other:
Seen & Returned: BC
P
ROB
MC
CD
OTH:
Attached: BC
P
ROB
MC
CD
OTH:
APPLICATION APPROVAL
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