Ds-11 - Application For A U.s. Passport (Page 5 of 6) in pdf

APPLICATION FOR A U.S. PASSPORT

OMB APPROVAL NO. 1405-0004

EXPIRATION DATE: 12-31-2013

Please Print Legibly Using Black Ink Only

ESTIMATED BURDEN: 85 MIN

Attention: Read WARNING on page 1 of instructions

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

U.S. Passport Book

Both

U.S. Passport Card

The U.S. passport card is not valid for international air travel. For more information see page 1 of instructions.

28 Page Book (Standard)

52 Page Book (Non-Standard)

Note: The 52 page option is for those who frequently travel abroad during the passport validity period and is recommended

for applicants who have previously required the addition of visa pages.

1. Name Last

DOTS Code

End. #

Exp.

First

Middle

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

4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.)

3. Sex

6. Email Address (e.g. )

5. Social Security Number

7. Primary Contact Phone Number

8. Mailing Address: Line 1: Street/RFD#, P.O. Box, or URB.

Address Line 2: Clearly label Apartment, Company, Suite, Unit, Building, Floor, In Care Of or Attention if applicable. (e.g. In Care Of - Jane Doe, Apt # 100)

City

State

Zip Code

Country, if outside the United States

9. List all other names you have used. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed)

10. Parental Information

Mother/Father/Parent - First & Middle Name

Last Name (at Parent's Birth)

Date of Birth (mm/dd/yyyy)

Place of Birth

Sex

U.S. Citizen?

Male

Yes

Female

Mother/Father/Parent - First & Middle Name

Last Name (at Parent's Birth)

Date of Birth (mm/dd/yyyy)

Place of Birth

Sex

U.S. Citizen?

Male

Yes

Female

Submit a recent,

color photograph

CONTINUE TO PAGE 2

DO NOT SIGN APPLICATION UNTIL REQUESTED TO DO SO BY AUTHORIZED AGENT

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 one of the instructions to the application form.

Identifying Documents - Applicant or Mother/Father/Parent on Second Signature Line (if identifying minor)

Driver's License

Issue

Exp.

Place of

Date

Issue

Applicant's Legal Signature - age 16 and older

Passport

Name

Military

Other