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WARNING: False statements made knowingly and willfully in passport applications, including affidavits or other documents submitted to support this application, are punishable by fine and/or imprisonment under U.S. law including the provisions of 18 U.S.C. 1001, 18 U.S. C. 1542, and/or 18 U.S.C. 1621. Alteration or mutilation of a passport issued pursuant to this application is punishable by fine and/or imprisonm ent under the provisions of 18 U.S.C. 1543. The use of a passport in violation of the restrictions contained herein or of the passport regul ations is punishable by fine and/or imprisonment under 18 U.S.C. 1544. All statements and documents are subject to verification. IMPORTANT NOTICE TO APPLICANTS WHO HAVE HAD A PREVIOUS U.S. PASSPORT BOOK AND/OR PASSPORT CARD AS DIRECTED BY PUBLIC LAW 106-113 AND 22 CFR 51.28: To submit an application for a child under age 16 both parents or the child's legal guardian(s) must appear and present the following: - Evidence of the child's U.S. citizenship; - Evidence of the child's relationship to parents/guardian(s); AND - Parental/guardian government-issued identification. IF ONLY ONE PARENT APPEARS, YOU MUST ALSO SUBMIT ONE OF THE FOLLOWING: - Second parent's notarized written statement or DS-3053 (including the child's full name and date of birth) consenting to the passport issuance for the child. The notarized statement cannot be more than three months old and must be signed and notarized on the same day, and must come with a photocopy of the front and back side of the second parent's government-issued photo identification; OR - Second parent’s death certificate if second parent is deceased; OR - Primary evidence of sole authority to apply; OR - A written statement or DS-5525 (made under penalty of perjury) explaining in detail the second parent's unavailability. AS DIRECTED BY REGULATION 22 C.F.R. 51.21 AND 51.28: - Each minor child applying for a U.S. passport book and/or passport card must appear in person. SPECIAL REQUIREMENTS FOR CHILDREN FAILURE TO PROVIDE INFORMATION REQUESTED ON THIS FORM, INCLUDING YOUR SOCIAL SECURITY NUMBER, MAY RESULT IN SIGNIFICANT PROCESSING DELAYS AND/OR THE DENIAL OF YOUR APPLICATION. INFORMATION, QUESTIONS, AND INQUIRIES U.S. PASSPORTS, EITHER IN BOOK OR CARD FORMAT, ARE ISSUED ONLY TO U.S. CITIZENS OR NON-CITIZEN NATIONALS. EACH PERSON MUST OBTAIN HIS OR HER OWN U.S. PASSPORT BOOK OR U.S. PASSPORT CARD. THE PA SSPORT CARD IS A U.S. PASSPORT ISSUED IN CARD FORMAT. LIKE THE TR ADITIONAL U.S. PASSPORT BOOK, IT REFLECTS THE BEARER'S ORIGIN, IDENTI TY, AND NATIO NALITY AND IS SUBJECT TO EXISTING PASSPORT LAWS AND RE GULATIONS. UNLIKE THE U.S. PASSPORT BO OK, THE U.S. PASSPORT CARD IS VALID ONLY FOR ENTRY TO THE UNITED STATES AT LAND BORDER CROSSINGS AND SEA PORTS OF ENTRY WHEN TRAV ELING FROM CANADA, MEXICO, THE CARIBBEAN, AND BERMUDA. THE U.S. PASSPORT CARD IS NOT VALID FOR INTERNATIONAL AIR TRAVEL. Please visit our website at travel.state.gov . In addition, you may contact the National Passport Information Center (NPIC) toll-free at 1-877-487-2778 (TDD: 1-888-874-7793) or by email at NPIC@state.gov. Customer Service Representatives are available Monday-Friday 8:00a.m.-10:00p.m. Eastern Time (excluding federal holidays). Automated information is available 24 hours a day, 7 days a week. APPLICATION FOR A U.S. PASSPORT PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS I applied: DS-11 09-2013 Place: Date: Instruction Page 1 of 4 WHAT TO SUBMIT WITH THIS FORM: 1. PROOF OF U.S. CITIZENSHIP (Evidence of U.S. citizenship that is not damaged, altered, or forged will be returned to you.) 2. PROOF OF IDENTITY (You must present your original identification AND submit a photocopy of the front and back side with your passport application.) 3. RECENT COLOR PHOTOGRAPH (Photograph must meet passport requirements – full front view of the face and 2x2 inches in size.) 4. FEES (Please visit our website at travel.state.gov for current fees.) WHERE TO SUBMIT THIS FORM: Please complete and submit this application in person to one of the following acceptance agents: a clerk of a federal or state court of record or a judge or clerk of a probate court accepting applications; a designated municipal or county official; a designated postal employee at an authorized post office; an agent at a passport agency (by appointment only); or a U.S. consular offi cial at a U.S. Embassy or Consulate, if abroad. To find you r nearest acceptance facility, visit travel.state.gov or contact the National Passport Information Center at 1-877-487-2778. LOST OR STOLEN - You are required to submit a Form DS-64, Statement Regarding a Lost or Stolen U.S. Passport, when your valid or potentially valid U.S. passport book and/or passport card cannot be submitted with this application. IN MY POSSESSION - If your most recent U.S.passport book and/or passport card was issued less than 15 years ago, and you were over the age of 16 at the time of issuance, you may be eligible to use Form DS-82 to renew your passport by mail. If your most recent passport is valid and needs additional pages, you can submit your passport, form DS-4085, and the current fee. See page 2 of the instructions for detailed information on the completion and submission of this form. APPLICATION FOR A U.S. PASSPORT
The passport processing, execution, and security f ees may be paid in any of the following forms: Checks (personal, certified, or traveler's) with the applicant's full name
and date of birth printed on the front; major credit card (Visa, Master Card, American Express, and Discover); bank draft or cashier's check; money order (U.S. Postal, international,
currency exchange), or if abroad, the foreign currency equivalent, or a check drawn on a U.S. bank . All fees should be payable to the "U.S. Department of State " or if abroad, the
appropriate U.S. Embassy or U.S. Consulat e. When applying at a designat ed acceptance facility, the execution fee will be paid separately and should be made payable to the
acceptance facility. NOTE: Some designated acceptance facilities do not accept credit cards as a form of payment.
For faster processing, you may request expedited service. Please include the expedite fee in your payment. Our website contains updated information r egarding fees and
processing times for expedited service. Expedited service is available only in the United States.
If you desire OVERNIGHT DELIVERY SERVICE for the return of your passport, please include the appropriate fee with your payment.
An additional fee will be charged when, upon y our request, the U.S. Departm ent of State verifies iss uance of a previous U.S. passport or Consular Report of Birth Abroad
because you are unable to submit evidence of U.S. citizenship.
For applicants with U.S. government or military authorization for no-fee passports, no fees are charged exc ept the execution fee when applying at a designated
acceptance facility.
1. PROOF OF U.S. CITIZENSHIP
You may submit items such as the following containing your signature AND a photograph that is a good likeness of you: previous or current U.S. passport book; previous or current
U.S. passport card; driver's license (not te mporary or learner's license); Certificate of Naturalization; Certificate of Citize nship; military identification; or federal, state, or municipal
government employee identification card. Temporary or altered documents are not acceptable.
You must establish your identity to the sa tisfaction of the acceptanc e agent and Passport Services. We may ask you to provide additional evidence to est ablish your identity. If
you have changed your name, please see travel.state.gov for instructions.
IF YOU CANNOT PROVIDE DOCUMENTARY EVIDENCE OF IDENTITY as st ated above, you must appear with an IDENTIFYING WITNESS who is a U. S. citizen, non-citizen
U.S. national, or permanent resident alien who has known you for at least two years. Y our witness must prove his or her identit y and complete and sign an Affidavit of Identifying
Witness (Form DS-71) before the acceptance agent. You must also submit some identification of your own.
Submit a color photograph of you alone, sufficiently recent to be a good likeness of you (taken with in the last six months), an d 2x2 inches in size. The image size measured from
the bottom of your chin to the top of your head (including hair) should not be less than 1 inch, and not more than 1 3/8 inches. The photograph must be color, clear, with a full front
view of your face, and printed on photo quality paper with a plai n light (white or off-white) background. The photograph must b e taken in normal street attire, without a hat, head
covering, or dark glasses unless a signed stat ement is submitted by the applicant verify ing the item is worn daily for religiou s purposes or a signed doctor' s statement is submitted
verifying the item is used daily for medical purposes. Headphones, "bluetooth", or similar devices must not be worn in the passport photograph. Any photograph retouched so that
your appearance is changed is unacc eptable. A snapshot, most vending machine pr ints, and magazine or full-length photographs ar e unacceptable. A digital photo must meet the
previously stated qualifications, and will be accepted for use at the discretion of Passport Services. Visit our website at travel.state.gov for details and information.
CURRENT FEES ARE LISTED ON OUR WEBSITE AT TRAVEL.STATE.GOV. BY LAW, THE PASSPORT FEES ARE NON-REFUNDABLE.
DS-11 09-2013
2. PROOF OF IDENTITY
3. RECENT COLOR PHOTOGRAPH
4. FEES
Instruction Page 2 of 4
APPLICANTS BORN IN THE UNITED STATES: Submit a previous U.S. passport or certified birth certificate. Passpor ts that are limited in validity will need to be supplemented
by other evidence. A birth ce rtificate must include your full name, date and plac e of birth, sex, date the birth record was fi led, the seal or other certific ation of the official custodian
of such records (state, county, or city/town office), and the full names of your parent(s).
- If the birth certificate was filed more than 1 year after the birth: It must be supported by evidence described in the next paragraph.
- If no birth record exists: Submit a registrar's notice to that effect. Also, submit a combination of the evidence listed below, which should include your given name and surname,
date and/or place of birth, and the seal or other certification of the office (if customary), and the signature of the issuing official.
A hospital birth record;
An early baptismal or circumcision certificate;
Early census, school, medical, or family Bible records;
Insurance files or published birth announcements (such as a newspaper article); and
Notarized affidavits (or DS-10, Birth Affidavit) of older blood relatives having knowledge of your birth may be submitted in addition to some of the records
listed above.
APPLICANTS BORN OUTSIDE THE UNITED STATES : Submit a previous U.S. pass port, Certificate of Naturalizat ion, Certificate of Citizenshi p, Report of Birth Abroad, or
evidence described below:
- If you claim citizenship through naturalization of parent(s): Submit the Certificate(s) of Naturalization of your parent(s), your foreign birth certificate (and official translation if the
document is not in English), proof of your admission to the United States for permanent residence, and your parents' marriage/ce rtificate and/or evidence that you were in the
legal and physical custody of your U.S. citizen parent, if applicable.
- If you claim citizenship through birth abroad to at least one U.S. citizen parent
: Submit a Consular Report of Birth (Form FS-240), Certification of Birth (Form DS-1350 or
FS-545), or your foreign birth certificate (and official translation if the document is not in English), proof of U.S. citizenship of your parent, your parents' marriage certificate, and
an affidavit showing all of your U.S. citizen parents' periods and places of residence/physical presence in the United States and abroad before your birth.
- If you claim citizenship through adoption by a U.S. citizen parent(s): Submit evidence of your permanent residence status, full and final adoption, and your U.S. citizen
parent(s) evidence of legal and physical custody. (NOTE: Acquisition of U.S. citizenship for persons born abroad and adopted only applies if the applicant was born on or after
02/28/1983.)
ADDITIONAL EVIDENCE: You must establish your citizenship to the satisfaction of the acceptan ce agent and Passport Services. We may ask you to provide
additional evidence to establish your claim to U.S. citizenship. Visit travel.state.gov for details.
You may receive your newly issued passport book and/or card and your returned citize nship evidence in two separate mailings. I f you are applying for both a U.S.
passport book and passport card, you may recei ve three separate mailings; one with your returned citizenship evidence, one with your newly issued passport book,
and one with your newly issued passport card.
If you are 16 years of age or older: Your U.S. passport will be valid for 10 years from the date of issue except where limited by the Secretary of State to a shorter period.
(See information below about the additional cost for expedited service.)
If you are under 16 years of age: Your U.S. passport will be valid for five years from the date of issue except where limited by the Secretary of State to a shorter period.
(See information below about the additional cost for expedited service.)DS-11 09-2013 FEDERAL TAX LAW Section 6039E of the Internal Revenue Code (2 6 U.S.C. 6039E) requires you to provide your Social Security number (SSN), if you have one, when you apply for or renew a U.S. pa ssport. If you have not been issued a SSN, enter zeros in box #5 of this form. If you are res iding abroad, you must also provide the name of the foreign country in which you are re siding. The U.S. Department of State must provide your SSN and foreign residence information to the U.S. Department of Treasury. If you fail to provide the information, you are subject to a $500 penalty enfo rced by the IRS. All questions on this matter should be directed to the nearest IRS office. If you send us a check, it will be converted into an electronic fu nds transfer (EFT). This means we will copy your check and u se the account information on it to electronically debit your account for the amount of the check. The debit from your account will usually o ccur within 24 hours and will be shown on your regular account statement. You will not receive your original check back. We will destroy your original check, but we will keep the copy of it. If the EFT cannot be processed for technical reasons, you authorize us to process the copy in place of your original check. If t he EFT cannot be completed becaus e of insufficient funds, we may try to make the transfer up to two times, and we will charge you a one-time fee of $25, which we will also collect by EFT. NOTICE TO CUSTOMERS APPLYING OUTSIDE A STATE DEPARTMENT FACILITY Passport service fees are established by law and regulation (see 22 U.S.C. 214, 22 C.F.R. 22.1, and 22 C.F. R. 51.50-56), and ar e collected at the time you apply for the passport service. If the Department fails to receive full payment of the applicable fees because, for e xample, your check is returned for any reason or you dispute a passport fee charge to your credit card, the U.S. Depart ment of State will take action to collect the delinquent fees from you under 22 C.F.R. Part 34, and the Federal Claims Collecti on Standards (see 31 C.F.R. Parts 900-904). I n accordance with the Debt Collection Improvement Act (Pub. L. 104-134), if the fees remain unpaid afte r 180 days and no repayment arrangements ha ve been made, the Department will refer the debt to the U. S. Department of Treasury for collection. Debt collection procedures used by U.S. Department of Treasury may include referral of the debt to private collection agencies , reporting of the debt to credit bureaus, garnishment of private wages and administrative offset of the debt by reduc ing, or withholding eligible federal payme nts (e.g., tax refunds, social security pay ments, federal retirement, etc.) by the amount of your debt, including any interest penalti es or other costs incurred. In addition, non-payment of passport fees may result in the invalidation of your passport. An invalidated passport cannot be used for travel. REMITTANCE OF FEES OTHER USES OF SOCIAL SECURITY NUMBER For more information regarding reporting a lost or stolen U.S. passport book or passport card and the Form DS-64, your eligibility to submit a Form DS-82 or how to request additional visa pages, call NPIC at 1-877-487-2778 or visit travel.state.gov. Your Social Security number will be prov ided to U.S. Department of Treasury, used in connection with debt collection and checke d against lists of persons ineligible or potentially ineligible to receive a U.S. passport, among other authorized uses. PROTECT YOURSELF AGAINST IDENTITY THEFT! REPORT YOUR LOST OR STOLEN PASSPORT BOOK OR PASSPORT CARD! NOTICE TO APPLICANTS FOR OFFICIAL, DIPLOMATIC, OR NO-FEE PASSPORTS You may use this application if you meet all of the provisions listed on Instruction Page 2, how ever, you must CONSULT YOUR SPO NSORING AGENCY FOR INSTRUCTIONS ON PROPER ROUTING PROCEDURES BEFORE FORWARDING THIS APPLICATION. Your completed passport will be released to your sponsoring agency for forwarding to you. Passport Services will not mail a U.S. passport to a private address outside the United States. If you do not live at the addr ess listed in the "mailing address", then you must put the name of the person and mark it as "In Care Of" in item # 8. If your mailing address changes prior to rec eipt of your new passport, please contact the National Passport Information Center. If you choose to provide your email address in Item #6 on this app lication, Passport Services may use that information to conta ct you in the event there is a problem with your application or if you need to provide information to us. SPECIAL NOTICE TO U.S. PASSPORT CARD APPLICANTS ONLY The maximum number of letters provided for your given name (fir st and middle) on the U.S. passpor t card is 24 characters. The 24 characters may be shortened due to printing restrictions. If both your given names are more than 24 characters, you must shorten one of your given names you list on item 1 of this form. NOTE REGARDING MAILING ADDRESSES Instruction Page 3 of 4
DS-11 09-2013 ACTS OR CONDITIONS If any of the below-mentioned acts or conditions have been perfo rmed by or apply to the applicant, the portion which applies sh ould be lined out, and a supplementary explanatory statement under oath (or affirmation) by the applicant should be attached and made a part of this application. I have not, since acquiring United States ci tizenship/nationality, been naturalized as a citizen of a foreign state; taken an o ath or made an affirmation or other formal decl aration of allegiance to a foreign state; enter ed or served in the armed forces of a foreign st ate; accepted or performed the duties of any office, post, or employment under th e government of a foreign stat e or political subdivision thereo f; made a formal renunciation of nationality either in the United States, or before a diplomatic or consular office r of the United States in a f oreign state; or been convicted by a court or court martial of competent jurisdicti on of committing any act of treason against, or attempting by forc e to overthrow, or bearing arms against, the United States, or conspiring to overthrow, put down, or to destroy by force, the government of the United States. Furthermore, I have not been convicted of a federal or state drug of fense or convicted of a "sex tourism" crimes statute, and I am not the subject of an outstanding federal, state, or local warrant of arrest for a felony; a crimin al court order forbidding my departure from the United States; a subpoena received from the United States in a matter involving federal prosecution for, or grand jury investigation of, a felony. PRIVACY ACT STATEMENT AUTHORITIES: Collection of this information is authorized by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E, Section 236 of the Admiral James W. Nance and Meg Donovan Foreign Relations Authorizat ion Act, Fiscal Years 2000 and 2001; Executive Order 11295 (August 5 , 1966); and 22 C.F.R. parts 50 and 51. PURPOSE: We are requesting this information in order to determine your eligibility to be issued a U.S. passport. Your Social Securit y number is requested in order to verify your identity. Failure to provide your Social Security number on this form may delay processing of your application. ROUTINE USES: This information may be disclosed to another domestic governm ent agency, a private contractor, a foreign government agency, or to a private person or private employer in accordance with certain approved routine uses. These routine uses include, but a re not limited to, law enforcement activities, employment verifi cation, fraud prevention, border security, counterterrorism, litigation activities, and activities that meet the Secretary of State's responsibility to protect U.S. citizens and non-citizen nationals abroad. More information on the Routine Uses for the system can be found in System of Records Notices State-05, Overseas Citizen Services Records and State-26, Passport Records. DISCLOSURE: Providing your Social Security number and the other informatio n on this form is voluntary, but failure to provide the informa tion on this form may, given the form's purpose of verification of ident ity and entitlement to a U.S. passport, result in processing de lays or denial of the passport application. Failure to provide your Social Security num ber may also subject you to a penalty enforc ed by the Internal Revenue Service, as d escribed in the Federal Tax Law section of the instructions to this form. Your Social Security num ber will be provided to the Department of th e Treasury and may be used in connection with debt collection, among other purposes as authorized and generally described in this section. Provid ing your Social Security number and other information requested on this form is otherwise voluntary. ELECTRONIC PASSPORT STATEMENT The U.S. Department of State now issues an "Electronic Passport" book, which contains an embedded electronic chip. The electro nic passport book continues to be proof of the bearer's United States citizenship/nationality and identity, and looks and functions in the same way as a passport without a chip. The addition of an electronic chip in the back cover enables the passport book to carry a duplicate electronic copy of all information from the data page. The electronic passport book is usable at all ports-of-entry, including those that do not yet have electronic chip readers. Use of the electronic format provides the traveler the additional security protection s inherent in chip technology. Moreover, when used at ports-of-entry equipped with electronic chip readers, the electronic passport book provi des for faster clearance through some o f the port-of-entry processes. The electronic passport book does not require special handling or treatment, but like previous ve rsions should be protected fro m extreme heat, bending, and from immersion in water. The electronic chip must be read using specia lly formatted readers, which protects the d ata on the chip from unauthorized reading. The cover of the electronic passport book is printed with a spec ial symbol representing the embedded chip. The symbol will appear in port-of-entry areas where the electronic passport book can be read. PAPERWORK REDUCTION ACT STATEMENT Public reporting burden for this collection of information is es timated to average 95 minutes per response, including the time required for searching existing data sources, gathering the necessary data, providing t he information and/or documents required, and reviewing the fin al collection. You do not have to supply this information unless this collection di splays a currently valid OMB control number. If you have comme nts on the accuracy of this burden estimate and/or recommendati ons for reducing it, please send them to: U. S. Department of Stat e, Bureau of Consul ar Affairs, Passport Services, Office of Program Management and Operational Support, 2201 C Street NW, Washington, D.C. 20520. Instruction Page 4 of 4
4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.) APPLICATION FOR A U.S. PASSPORT x x Mother/Father/Parent/Legal Guardian's Signature (if identifying minor) x Mother/Father/Parent/Legal Guardian's Signature (if identifying minor) Applicant's Legal Signature - age 16 and older DO NOT SIGN APPLICATION UNTIL REQUESTED TO DO SO BY AUTHORIZED AGENT OMB CONTROL NO. 1405-0004 OMB EXPIRATION DATE: 01-31-2017 ESTIMATED BURDEN: 95 MIN Please Print Legibly Using Black Ink Only Attention: Read WARNING on page 1 of instructions Please select the document(s) for which you are applying: D OD e p End. # Exp. First Middle - - MF A. B. I declare under penalty of perjury all of the following: 1) I am a citizen or non-citizen nat ional of the United States and have not, since acquiring U.S. ci tizenship or nationality, performed any of the acts listed under "Acts or Conditions" on page four of the instructions 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) t he photograph attached to 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. (Seal) Acceptance Agent (Vice) Consul USA Passport Staff Agent * DS 11 C 09 2013 1 *Bk Postage Execution OtherEFFor Issuing Office Only Date Facility Name/Location Identifying Documents - Applicant or Mother/Father/Parent on Second Signature Line (if identifying minor) DS-11 09-2013 Page 1 of 2 DOTS Facility ID Number Agent ID Number 3. Sex Signature of person authorized to accept applications STOP! CONTINUE TO PAGE 2 U.S. Passport CardU.S. Passport Book 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. 52 Page Book (Non-Standard) -- City Zip Code 6. Email Address (e.g., my_email@domain.com) @ 7. Primary Contact Phone Number -- 1. Name Last Country, if outside the United StatesState 9. List all other names you have used. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed) 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) 8. Mailing Address: Line 1: Street/RFD#, P.O. Box, or URB. 5. Social Security Number Card 2. Date of Birth (mm/dd/yyyy) Both 28 Page Book (Standard) The U.S. passport card is not valid for international air travel. For more information see page 1 of instructions. Driver's License ID No Passport Military Other Country of Issuance State Issued ID Card Identifying Documents - Applicant or Mother/Father/Parent on Third Signature Line (if identifying minor) STAPLE 2" x 2" STAPLE STAPLE 2" x 2" STAPLE Attach a color photograph taken within the last six months Name Driver's License ID No Issue Date (mm/dd/yyyy) Exp. Date (mm/dd/yyyy) State of Issuance Passport Military Other Country of Issuance State Issued ID Card Name Name of courier company (if applicable) Issue Date (mm/dd/yyyy) Exp. Date (mm/dd/yyyy) State of Issuance
18. Travel Plans Departure Date (mm/dd/yyyy) Return Date (mm/dd/yyyy) Countries to be Visited City Zip CodeState Apartment/Unit 19. 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) 13. Occupation (if age 16 or older) 14. Employer or School (if applicable) Home Cell Work 12. Additional Contact Phone Number Mother/Father/Parent - First & Middle Name Last Name (at Parent's Birth) Date of Birth (mm/dd/yyyy) Place of Birth 10. Parental Information Male Female Yes No U.S. Citizen?Sex 21. Have you ever applied for or been issued a U.S. Passport Book or Passport Card? Name as printed on your most recent passport book Yes No If yes, complete the remaining items in #21. PLEASE DO NOT WRITE BELOW THIS LINE - FOR ISSUING OFFICE ONLY Name as it appears on citizenship evidence Birth Certificate SR CR City Filed: Issued: Passport C/R S/R Per PIERS #/DOI: Attached: * DS 11 C 09 2013 2 * P/C of ID DS-5520DS-3053 DS-64 DS-5513 Citz W/S DS-10 DS-71DS-86 IRL CIS Ver 20. 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 DS-11 09-2013 Page 2 of 2 Date of Birth (mm/dd/yyyy)Name of Applicant (Last, First, & Middle) Name as printed on your most recent passport card - - Mother/Father/Parent - First & Middle Name Last Name (at Parent's Birth) Date of Birth (mm/dd/yyyy) Place of Birth Male Female Yes No U.S. Citizen?Sex - - -- Report of Birth Filed/Place: Nat. / Citz. Cert. USCIS USDC Date/Place Acquired: A# Other: If yes, complete the remaining items in #11. Date of Marriage (mm/dd/yyyy) 11. Have you ever been married? Full Name of Current Spouse or Most Recent Spouse Date of Birth (mm/dd/yyyy) Have you ever been widowed or divorced? Place of Birth Yes No Widow/Divorce Date (mm/dd/yyyy) Yes No Yes No U.S. Citizen? - - 15. Height 16. Hair Color 17. Eye Color Status of your most recent passport book: Submitting with application Stolen Lost In my possession (if expired) Status of your most recent passport card: Submitting with application Stolen Lost In my possession (if expired) Most recent passport book number Most recent passport book issue date (mm/dd/yyyy) Most recent passport card number Most recent passport card issue date (mm/dd/yyyy) P/C of Citz