Fillable Application For A U.s. Passport By Mail (Page 5 of 6) in pdf

APPLICATION FOR A U.S. PASSPORT BY MAIL

OMB APPROVAL NO. 1405-0020

EXPIRATION DATE: 12-31-2010

ESTIMATED BURDEN: 40 MIN

Attention: see WARNING on page two of instructions

Please select the document (or documents) for which you are applying:

U.S. Passport Book

U.S. Passport Card

The U.S. passport card may only be used for international travel by land or sea between the United States,

Canada, Mexico, the Caribbean and Bermuda.

Please visit our website for detailed information.

1. Name Last

End. #__________

Exp ____________

First & Middle

2. Date of Birth (mm/dd/yyyy)

4. Place of Birth (City & State or City & Country as it is presently known)

5. Social Security Number

3. Sex

6. Mailing Address: Street/RFD # or P.O. Box

Apartment or unit #

City

State

Zip Code (Zip + 4 if known)

In Care Of or Country, if applicable

7. Contact Phone Number

8. Email Address (Optional)

Home

Cell

Work

9. Have You Ever Used A Different Name (Maiden, Previous Marriage, Legal Name Change)? If yes, please complete.

(Attach additional pages if needed)

10. Passport Book or Passport Card Information

Your name as listed on your most recent passport or passport card

Issue date (mm/dd/yyyy)

Most recent passport book or passport card

11. Name Change Information - Complete if name is different than last passport book or passport card

Place of Name Change (City/State)

Date (mm/dd/yyyy)

Changed by Marriage

Changed by Court Order

Submit two recent,

Please submit marriage certificate or court order to support your name change.

color photographs

CONTINUE TO PAGE 2

YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW

I declare under penalty of perjury all of the following: 1)I am a citizen or non-citizen national of the United States and have not, since acquiring U.S. citizenship or nationality,

performed any of the acts listed under “Acts or Conditions” on the reverse side of this application (unless explanatory statement is attached); 2)the statements made on the

application are true and correct; 3)I have not knowingly and willfully made false statements or included false documents in support of this application; 4)the photograph

submitted with this application is a genuine, current, photograph of me; and 5)I have read and understood the warning on page two of the instructions to the application form.

x _________________________________________________

_________________________________________________

Applicant’s Signature

Date

This section for issuing office only

Marriage Certificate

Date of Marriage/Place Issued:

Court Order

Date Filed/Court:

Other:

Attached:

PPT Fee________