Form Ds-82 - U.s. Passport Renewal Application For Eligible Individuals Page 6
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6Name of Applicant (Last, First & Middle)
Date of Birth (mm/dd/yyyy)
12. Height
13. Hair Color
14. Eye Color
15. Occupation
16. Employer or School (if applicable)
17. Additional Contact Phone Numbers
Home
Cell
Home
Cell
Work
Work
18. 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
19. Emergency Contact - Provide the information of a person not traveling with you to be contacted in the event of an emergency.
Name
Address: Street/RFD # or P.O. Box
Apartment/Unit
City
State
Zip Code
Phone Number
Relationship
20. Travel Plans
Departure Date (mm/dd/yyyy)
Return Date (mm/dd/yyyy)
Countries to be visited
STOP! YOU HAVE COMPLETED YOUR APPLICATION
BE SURE TO SIGN AND DATE PAGE ONE
* DS 82 C 08 2013 2 *
DS-82 08-2013
Page 2 of 2
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