Ds-11 - Application For A U.s. Passport Page 6
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1
2
3
4
5
6Date of Birth (mm/dd/yyyy)
Name of Applicant (Last, First & Middle)
11. Height
12. Hair Color
13. Eye Color
14. Occupation (if age 16 or older)
15. Employer or School (if applicable)
16. Additional Contact Phone Numbers
Home
Cell
Home
Cell
Work
Work
17. 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
18. 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
19. Travel Plans
Date of Trip (mm/dd/yyyy) Duration of Trip
Countries to be Visited
20. Have you ever been married?
Yes
No
If yes, complete the remaining items in #20.
Full Name of Current Spouse or Most Recent Spouse
Date of Birth (mm/dd/yyyy)
Place of Birth
U.S. Citizen?
Yes
No
Yes
Date of Marriage
Have you ever been widowed or divorced?
Date (mm/dd/yyyy)
(mm/dd/yyyy)
No
21. Have you ever applied for or been issued a U.S. Passport Book?
Yes
No
If yes, complete the remaining items in #21
Name as printed on your most recent passport book
Most recent passport book number
Status of your most recent passport book
Date most recent passport book was issued
Submitting with application
Stolen
Lost
In my possession (if expired)
or approximate date you applied (mm/dd/yyyy)
22. Have you ever applied for or been issued a U.S. Passport Card?
Yes
No
If yes, complete the remaining items in #22
Name as printed on your most recent passport card
Most recent passport card number
Status of your most recent passport card
Date most recent passport card was issued
Submitting with application
Stolen
Lost
In my possession (if expired)
or approximate date you applied (mm/dd/yyyy)
PLEASE DO NOT WRITE BELOW THIS LINE
FOR ISSUING OFFICE ONLY
Sole Parent
Name as it appears on citizenship evidence
Birth Certificate
SR
CR
City
Filed:
Issued:
Report of Birth
240
545
1350
Filed/City:
Nat. / Citz. Cert.
Date/Place Acquired:
A#
Passport
C/R
S/R
Per PIERS
#/DOI:
Other:
Attached:
Citz W/S
DS-86
P/C of ID
DS-3053
DS-64
Bio Quest
DS-10
DS-71
DS-60
* DS 11 C 12 2010 2 *
DS-11 12-2010
Page 2 of 2
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