Us Passport Application Form Page 6
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6Name of Applicant (Last, First & Middle)
Date of Birth (mm/dd/yyyy)
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
Zip Code
State
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
Please complete the following questions regarding your current passport book and/or passport card
Has your name changed by marriage or court
Current Name Last
order since your passport book or passport
card was issued?
Yes
No
First
Middle
If yes, please complete this section with your
current information.
Note: To complete a name change your submitted passport book and/or passport card must be less than one year old.
Please submit evidence documenting your name change (such as a certified marriage certificate or court order) and your current passport book
and/or passport card, along with this completed form to the address listed on page 2 of the instructions.
Was your identifying information printed
Name Last
incorrectly in your passport book or
passport card?
First
Middle
Yes
No
If yes, please complete the information as it should
appear, and check only the box(s) next to the
Date of Birth (mm/dd/yyyy)
Place of Birth (State or Country)
Sex
field(s) to be corrected.
M
F
Please submit evidence documenting your correct identifying information (such as a certified marriage certificate or birth certificate) and your
current passport book and/or passport card, along with this completed form to the address listed on page 2 of the instructions.
Note: To complete a limited passport book replacement your submitted passport book
Was your most recent passport limited for
must not be expired. Passport books limited in validity because of multiple losses cannot
one year or less?
be extended.
Yes
No
Please be sure to enclose your passport book along with this application to the address
If yes, please submit evidence of your United States
listed on page 2 of the instructions.
citizenship and/or evidence of your identity.
* DS5504 C 12 2010 2 *
DS-5504 12-2010
Page 2 of 2
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