Renewal Regular Passport Application Form (Adult) Page 2

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13.
APPLICANT’S SPOUSE’S NAME:
14a.
14b.
PERSON TO CONTACT IN CASE OF EMERGENCY:
TEL/MOBILE NO. OF PERSON TO NOTIFY:
PARENTAL INFORMATION
CURRENT PASSPORT DETAILS
15.FATHER’S DETAILS
16. MOTHER’S DETAILS
17a.
PASSPORT NUMBER
Last Name:
Last Name:
First Name:
First Name:
17b.
DATE OF ISSUE
Middle Name:
Middle Name:
17c.
DATE OF EXPIRY
Citizenship
Citizenship
17d.
ISSUING AUTHORITY
(at time of applicant’s birth)
(at time of applicant’s birth)
STATUS OF CURRENT PASSPORT
19. Please choose as applicable:
Lost Valid Passport
 Affidavit of Loss
Passport Intact
 Police Report in English
Damaged Passport
 Affidavit of Explanation
Lost Expired Passport
 Affidavit of Explanation
DECLARATION OF APPLICANTS
I HEREBY DECLARE AND AFFIRM that 1) I am a Filipino citizen. 2) The information provided in this application is
true and correct. 3) The supporting documents attached are authentic. 4) I consent to the verification by the
Philippine Government of the information I provided to establish my personal particulars, and further consent to its
use for any lawful purpose. 5) I am aware that the information provided in this application will be treated in
accordance with relevant privacy regulations. 6) I am aware that under the law, I am allowed to hold only one valid
regular Philippine passport at a given time. 7) I am aware that making false statements in this passport application
and furnishing falsified or forged documents are punishable by fine or imprisonment, and grounds for suspension
or denial of application. 8) I understand and accept that the release of the passport could be subject to delay due
to unforeseen events beyond the control of the Department of Foreign Affairs.
_____________________________________
_______________________________
20. SIGNATURE OVER PRINTED NAME
21. DATE (ex. 01 Jan 2017)
DO NOT WRITE BELOW THIS LINE. FOR THE DEPARTMENT’S USE ONLY.
REMARKS:
PASSPORT WATCHLIST
R
ETURNED CANCELLED
VERIFICATION:
PASSPORT
SIGNATURE OF
APPLICANT:
PROCESSOR’S SIGNATURE:
ENCODER’S SIGNATURE:
OFFICIAL RECEIPT/PAYMENT SLIP NO:
DATE OF TRANSACTION:
END
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