DS 11 Application for a U.S. Passport

Transcript

1 U.S. PASSPORT APPLICATION PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS FOR INFORMATION AND QUESTIONS Visit the official Department of State website at travel.state.gov or contact the National Passport Information [email protected] 1-877-487-2778 (TDD: 1-888-874-7793) and Center (NPIC) via toll-free at 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. WHAT TO SUBMIT WITH THIS FORM: of the front (and back, if there is printed information) must be submitted 1. PROOF OF U.S. CITIZENSHIP: Evidence of U.S. citizenship AND a photocopy with your application. The photocopy must be on 8 ½ in ch by 11 inch paper, black and white ink, legible, and clear. Eviden ce that is not damaged, altered, or forged will be returned to you. Note: Lawful permanent resident cards submitted with this application will be forwarded to U.S. Citizenship and Immigration Services, if we determine that you are a U.S. citizen. 2. PROOF OF IDENTITY: You must present your original identification AND submit a photoc opy of the front and back with your passport application. Photograph must meet passport requirements – full fr 3. RECENT COLOR PHOTOGRAPH: ont view of the face and 2x2 inches in size. 4. FEES: website at travel.state.gov Please visit our for current fees. HOW TO SUBMIT THIS FORM: or a judge or clerk of a probate Complete and submit this application in person to a designated acceptance agent: a clerk of a federal or state court of record ice; an agent at a passport court accepting applications; a designated mu nicipal or county official; a designated postal employee at an authorized post off agency (by appointment only); or a U.S. cons ptance facility, visit ate, if abroad. To find your nearest acce ular official at a U.S. Embassy or Consul travel.state.gov or contact the National Passport Information Center at 1-877-487-2778. Follow the instructions on Page 2 for detailed information to completion and submission of this form. REQUIREMENTS FOR CHILDREN  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; tionship to parents/guardian(s); AND - Evidence of the child's rela - Original parental/guardian government-issued identification AND a photocopy of the front and back side of presented identification. ST ALSO SUBMIT ONE OF THE FOLLOWING: IF ONLY ONE PARENT APPEARS, YOU MU ng the child's full name and date of birth) consenting to the - Second parent's notarized written statement or DS-3053 (includi passport issuance for the child. The notarized statement cannot months old and must be more than three be signed and notarized on the same day, and must come with a photocopy of OR the front and back side of the second pa rent's government-issued photo identification; OR - Second parent’s death certificate if second parent is deceased; OR - Primary evidence of sole authority to apply, such as a court order; - A written statement or DS-5525 (made under penalty of perj ury) 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. PASSPORT VALIDITY LENGTH 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. : 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 If you are under 16 years of age shorter period. S. PASSPORT BOOK AND/OR PASSPORT CARD APPLICANTS WHO HAVE HAD A PREVIOUS U. LOST OR STOLEN If you cannot submit your valid or potentia lly valid U.S. passport book and/or passpor t card with this application and you have - not previously submitted Form DS-64, Statement Regarding a Lost or Stolen U.S. Passport, you are required to fill out and submi t a DS-64 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 use Form DS-82 to renew 16 at the time of issuance, you may be eligible to your passport by mail. FAILURE TO PROVIDE INFORMATION REQUESTED ON TH IS FORM, INCLUDING YOUR SOCIAL SECURITY NUMBER, LAYS AND/OR THE DENIAL OF YOUR APPLICATION. MAY RESULT IN SIGNIFICANT PROCESSING DE tted to support WARNING: False statements made knowingly and willfully in passport applications, including affidavits or other documents submi 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 ent under the U.S.C. 1621. Alteration or mutilation of a passport issued pursuant to this application is punishable by fine and/or imprisonm ations is punishable provisions of 18 U.S.C. 1543. The use of a passport in violation of the restrictions contained herein or of the passport regul by fine and/or imprisonment under 18 U.S.C. 1544. All statements and documents are subject to verification. DS-11 06-2016 Instruction Page 1 of 4

2 PROOF OF U.S. CITIZENSHIP APPLICANTS BORN IN THE UNITED STATES: birth certificate. Passports th at are limited in validity will need Submit a previous U.S. passport or certified birth record was filed, the seal or include your full name, date and place of birth, sex, date the to be supplemented by other evidence. A birth certificate must an of such records (state, county, or ci ty/town office), and the full names of your parent(s). other certification of the official custodi - : It must be supported by evidence described in the next paragraph. If the birth certificate was filed more than 1 year after the birth - If no birth record exists : Submit a registrar's notice to that effect. Also, submit a co mbination of the evidence listed below, which should include your given other certification of the office (if customary), and the signat ure of the issuing official. name and surname, date and/or place of birth, and the seal or  A hospital birth record;  An early baptismal or circumcision certificate; Early census, school, medical, or family Bible records;   Insurance files or published birth announc ements (such as a newspaper article); and  Notarized affidavits (or DS-10, Birth Affidavit) of older bl ood 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. passport, Certificate of Naturalization, Certificate of Citizenship, Consular Report of Birth Abroad, or evidence described below: - enship through naturalization of parent(s) : Submit the Certificate(s) of Naturalization of y our parent(s), your foreign birth certificate (and If you claim citiz of your admission to the United States for permanent residence, official translation if the document is not in English), proof and your parents' e that you were in the legal and physical custod y of your U.S. citizen parent, if applicable marriage/certificate and/or evidenc . - If you claim citizenship th rough birth abroad to at least one U.S. citizen parent : Submit a Consular Report of Birth (For m FS-240), Certification of Birth (Form DS-1350 or FS-545), or your foreign birth certificate (and offici al 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. ci tizen parents' periods and plac es of residence/physical presence in the United States and abroad before your birth. - If you claim citizens hip through adoption by a U.S. citizen pare nt(s) : Submit evidence of your permanent re sidence 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 pers ons 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 acceptance 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. PROOF OF IDENTITY You may submit items such as the following containing your signa or current U.S. passport ture AND a photograph that is a good likeness of you: previous book; previous or current U.S. passport card; driver's license ( not temporary or learner's license); Certificate of Naturalizat ion; Certificate of Citizenship; military identification; or federal, state, or municipal governm ent employee identification card . Temporary or altered document s are not a cceptable. additional evidence to You must establish your identity to the satisfaction of the ac ceptance agent and Passport Services. We may ask you to provide travel.state.gov establish your identity. If you have changed your name, please see for instructions. IF YOU CANNOT PROVIDE DOCUMENTARY EVIDENCE OF IDENTITY as stated above, you must appear with an IDENTIFYING WITNESS, who is a U .S. , or permanent resident alien that has known you citizen, non-citizen U.S. national for at least two years. Your witness must pr ove his or her identity and complete and sign an Affidavit of Identifying Witness (Form DS-71) before the acceptance agent. You must also submit some ident ification of your own. COLOR PHOTOGRAPH Submit a color photograph of you alone, sufficiently recent to be d 2x2 inches in size. The image a good likeness of you (taken within the last six months), an our head (including ha ir) should not be less than 1 inch, and not mor size measured from the bottom of your chin to the top of y e than 1 3/8 inches. The photograph must be in color, clear, with a full front view of your face. The photograph must be taken with a neutral facial exp ression (preferred) or a natural smile, and with both eyes open and be printed on photo quality paper with a plain light (white or off-white) background. The ph otograph must be taken in signed statement is submitted by the applicant verifying that th e hat or head covering is part of normal street attire, without a hat, or head covering unless a recognized, traditional religious attire that continuously when in public or a signed doc tor's statement is submitted is customarily or required to be worn verifying the item is used daily for medical purposes. Headphones, "bluetooth", or similar devices must not be worn in the pass port photograph. Glasses or ent from a doctor explaining why you cannot remove them due other eyewear are not acceptable unless you provide a signed statem to medical reasons (e.g., ouched so that your appearance is changed is unacceptable. A s napshot, most vending during the recovery period from eye surgery). Any photograph ret d magazine or full-length photographs are unacceptable. A digital photo must meet t machine prints, hand-held self portraits, an he previously stated accepted for use at the discretion of Passport Services. Visit our website at travel.state.gov qualifications, and will be for details and information. FEES . BY LAW, THE PASSPORT FEES ARE NON-REFUNDABLE. FEES ARE LISTED ON OUR WEBSITE AT TRAVEL.STATE.GOV  The passport application fee, security surcharge, and expedite fee 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 pr an Express, and Discover); bank inted on the front; major credit card (Visa, Master Card, Americ draft or cashier's check; money order (U.S. Postal, internatio nal, currency exchange), or if abroad, the foreign currency equiv alent, 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. Consulate. When applying at a designated 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. fee in your payment. Our website contains updated information  For faster processing , you may request expedited service. Please include the expedite pedited service is only available for passports mailed in the Uni ted States and Canada. regarding fees and processing times for expedited service. Ex  OVERNIGHT DELIVERY SERVICE is only available for passport book mailings in the United St ates. Please include the appropriate fee with your payment.  An additional fee will be charged when, upon your request, the U.S. Department of State verifies issuance of a previous U.S. p assport or Consular Report of Birth Abroad because you are unable to submit evidence of U.S. citizenship.  , no fees are charged except the execution fee when applying at a For applicants with U.S. government or military authorization for no-fee passports designated acceptance facility. DS-11 06-2016 Instruction Page 2 of 4

3 NOTE REGARDING MAILING OF YOUR PASSPORT(S) Passport Services will not mail a U.S. passport to a private addr ess outside the United States or Canada. If you do not live a t the address 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 c hanges prior to receipt of your new passport, please contact the Natio nal Passport Information Center. lication, Passport Services may use that information to conta If you choose to provide your email address in Item #6 on this app ct you in the event there is a problem with your application or if y ou need to provide information to us. You may receive your newly issued passport book and/ or card and your returned citizenship evidence in two separate mailings . If you are applying for both a U.S. passport book and passport card, you may receive three separate mailings ; one with your returned citizenship ev idence, one with your newly issued passport book, and one with your newly issued passport card. FEDERAL TAX LAW Section 6039E of the Internal Revenue Code ( 2714a(f) require you to provide your Social Security number (SSN), if 26 U.S.C. 6039E) and 22 U.S.C of this form. If you have one, when you apply for or renew a U.S. passport. If you have never been issued a SSN, you must enter zeros in box #5 of State must you are residing abroad, you must also provide the name of the fo reign country in which you are re siding. The U.S. Department provide your SSN and foreign residence information to the U.S. you fail to provide the informat ion, your application Department of the Treasury. If IRS. All questions on this matter should be referred to th may be denied and you are subject to a $500 penalty enforced by the e nearest IRS office. IDE A DEPARTMENT OF STATE FACILITY NOTICE TO CUSTOMERS APPLYING OUTS se the account 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 your account will usually o ccur within 24 hours and of the check. The debit from information on it to electronically debit your account for the amount will be shown on your r egular account statement. ur original check, but we will keep the copy of it. If the E FT cannot be processed for You will not receive your original check back. We will destroy yo technical reasons, you authorize us to process the copy in place of your original che ck. If the 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 collec t by EFT. FEE REMITTANCE 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 ment of State will take action your credit card, the U.S. Depart returned for any reason or you dispute a passport fee charge to to collect the Part 34, and the Federal Claims Collecti n accordance with delinquent fees from you under 22 C.F.R. on Standards (see 31 C.F.R. Parts 900-904). I the Debt Collection Improvement Act (Pub. L. 104-134), if the fees remain unpaid after 180 days and no repayment arrangements ha ve been made, the Department will refer the debt to the U.S. Department of Treasury for collect ion. Debt collection procedures used by U.S. Department of of private wages and Treasury may include referral of the debt to private collection age ncies, reporting of the debt to credit bureaus, garnishment administrative offset of the debt by reduci ng, or withholding eligible federal payments (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 passpo rt fees may result in the invalidation of your passport. An inva lidated passport cannot be used for travel. USE OF SOCIAL SECURITY NUMBER connection with debt collection and checke ded to U.S. Department of Treasury, used in d against lists of Your Social Security number will be provi receive a U.S. passport, among other authorized uses. persons ineligible or potentially ineligible to NOTICE TO APPLICANTS FOR OFFICIAL , DIPLOMATIC, OR NO-FEE PASSPORTS listed on Instruction Page 2; howe You may use this application if you meet all of the provisions ver, you must CONSULT YOUR SPO NSORING AGENCY FOR INSTRUCTIONS ON PROPER ROUTING PROCEDURES BEFORE FORWARDING THIS APPLICATION. Your completed passport ing agency for forwarding to you. will be released to your sponsor PROTECT YOURSELF AGAINST IDENTITY THEFT! REPORT YOUR LOST OR STOLEN PASSPORT BOOK OR PASSPORT CARD! r eligibility for a For more information regarding reporting a lo st or stolen U.S. passport book or passport card (Form DS-64), or to determine you . travel.state.gov passport renewal (Form DS-82), ca ll NPIC at 1-877- 487-2778 or visit APPLICANTS NOTICE TO U.S. PASSPORT CARD and middle) on the U.S. passport 24 characters may be The maximum number of letters provided for your given name (first card is 24 characters. The s are more than 24 characters, you must shorten one of your giv en names you list on item 1 of shortened due to printing restrictions. If both your given name this form. U.S. passports, either in book or card format, are only issued to obtain his or her own U.S. U.S. citizens or non-citizen U.S. nationals. Each person must passport issued in card format. Like the traditional U.S. pass port book, it reflects the passport book or U.S. passport card. The passport card is a U.S. subject to existing pass bearer's origin, identity, and nationality, and is Unlike the U.S. passport book, the U.S. passport card is port laws and regulations. valid only for entry at land border crossings and sea ports of entry when traveling from Canada, Mexico, the Caribbean, and Ber muda. The U.S. passport card is not valid for international air travel. DS-11 06-2016 Instruction Page 3 of 4

4 ELECTRONIC PASSPORT STATEMENT ns an embedded electronic chip. The electro The U.S. Department of State now issues an "Electronic Passport" book, which contai nic passport as a passport without a book continues to be proof of the bearer's U.S. citizenship/nationalit y and identity, and looks and functions in the same way ll information from the chip. The addition of an electronic chip in the back cover enables the passport book to carry a duplicate electronic copy of a eaders. data page. The electronic passport book is usable at all ports-o f-entry, including those that do not yet have electronic chip r when used at traveler the additional securi ty protections inherent in chip technology. Moreover, Use of the electronic format provides the ports-of-entry equipped with electroni provides for faster clearance through some o c chip readers, the electronic passport book f the port-of-entry processes. special handling or treatmen t, but like previous versi ons should be protected fro m extreme heat, The electronic passport book does not require bending, and from immersion in water. The electronic chip must be read using specially formatted readers, which protects the d ata on the chip from unauthorized reading. The cover of the electronic passport book is printed with a specia l symbol representing the embedded chip. The symbol will appear in port-of-entry areas w here the electronic passport book can be read. ACTS OR CONDITIONS If any of the below-mentioned acts or conditions have been perfo ould be lined out, rmed by or apply to the applicant, the portion which applies sh ion) by the applicant should be attached and made a part of th and a supplementary explanatory statement under oath (or affirmat is application. I have not, since acquiring United States citi citizen of a foreign state; taken an o ath or made an zenship/nationality, been naturalized as a affirmation or other formal decl aration of allegiance to a forei gn state; entered or served in the armed forces of a foreign st ate; accepted or reign state or political subdivision thereo employment under the government of a fo f; made a formal performed the duties of any office, post, or the United States, or before a diplomatic or consular officer of the United States in a f oreign state; or been renunciation of nationality either in convicted by a court or court martial of competent jurisdicti on against, or attempting by forc e to overthrow, or on of committing any act of treas w, put down, or to destroy by bearing arms against, the United States, or conspiring to overthro ited States. force, the government of the Un Furthermore, I have not been convicted of a feder al or state drug offense or convicted of a "sex tourism" crimes statute, and I am not the subject of t of arrest for a felony; a criminal c ourt order forbidding my departure from the United States; a an outstanding federal, state, or local warran al prosecution for, or grand jury investigation of, a felon y. subpoena received from the United States in a matter involving feder PRIVACY ACT STATEMENT AUTHORITIES: horized by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E , 22 U.S.C. 2714a(f), Collection of this information is aut Section 236 of the Admiral James W. Nance and Meg Donovan Fore ign Relations Authorization Act, Fiscal Years 2000 and 2001; Exec utive 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 Security number is used to verify your identity. ent agency, a private contractor, a foreign government agency, ROUTINE USES: This information may be disclosed to another domestic governm or to a private person or private employer ne uses. These routine uses include, but a re not limited to, law in accordance with certain approved routi enforcement activities, employment verifi cation, fraud prevention, border security, counterterrorism, litig ation activities, an d activities that meet the Secretary of State's responsibility to pr otect 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 St ate-26, Passport Records. DISCLOSURE: Providing information on this form is voluntary. Be advised, however, that failur e to provide the information requested on t his form may cause delays in processing your U.S. passport application and/or coul d result in the refusal or denial of your application. ) and may subject you application (consistent with 22 U.S.C. 2714a(f) Failure to provide your Social Security number may result in the denial of your form. Your Social to a penalty enforced by the Internal Revenue Service, as descri bed in the Federal Tax Law section of the instructions to this her purposes connection with debt collection, among ot Department of the Treasury and may be used in Security number will be provided to the authorized and generally described in this section. PAPERWORK REDUCTION ACT STATEMENT Public reporting burden for this collection of information is es timated to average 85 minutes per response, including the time required for searching existing data sources, gathering the necessary data, providing th required, and reviewing the fin al collection. You e information and/or documents 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 State, Bureau of Consul ar Affairs, Passport Services, Office of Le gal Affairs and Law Enforcement Liaison, 44132 Mercur e Cir, P.O. Box 1227, Sterling, Virginia 20 166-1227 DS-11 06-2016 Instruction Page 4 of 4

5 OMB CONTROL NO. 1405-0004 APPLICATION FOR A U.S. PASSPORT OMB EXPIRATION DATE: 08-31-2019 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. Large Book (Non-Standard) Regular Book (Standard) : The large book option is for those who frequently travel abroad during the passport validity period, and is Note recommended for applicants who have previously required the addition of visa pages. 1. Name Last DOTS D ODep End. # Exp. Middle First 4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.) (mm/dd/yyyy) 2. Date of Birth 3. Sex MF - - travel.state.gov ) 6. Email (Info alerts offered at 7. Primary Contact Phone Number 5. Social Security 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) , if outside the United States Country State City Zip Code (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed) 9. List all other names you have used. B. A. STOP! CONTINUE TO PAGE 2 STAPLE ED TO DO SO BY AUTHORIZED AGENT DO NOT SIGN APPLICATION UNTIL REQUEST Identifying Documents - Applicant or Mother/Father/Parent on Second Signature Line (if identifying minor) 2" x 2" Driver's License Military Other Passport State Issued ID Card STAPLE Name State of Exp. Date Issue Date Issuance (mm/dd/yyyy) (mm/dd/yyyy) STAPLE Country of ID No Issuance 2" x 2" Identifying Documents - Applicant or Mother/Father/Parent on Third Signature Line (if identifying minor) State Issued ID Card Driver's License Passport Military Other STAPLE Attach a color photograph taken within the last six months Name Issue Date Exp. Date State of Acceptance Agent (Vice) Consul USA (mm/dd/yyyy) Issuance (mm/dd/yyyy) Passport Staff Agent Country of ID No Issuance am a citizen or non-citizen nat ional of the United States and I declare under penalty of perjury all of the following: 1) I tizenship or nationality, performed any of the acts listed under "Acts or Conditions" on have not, since acquiring U.S. ci ions of this application (unles s explanatory statement is attached); 2) the statements made on the page four of the instruct (Seal) s or included false documents application are true and correct; 3) I have not knowingly and willfully made false statement is a genuine, current photograph of me; and he photograph attached to this application in support of this application; 4) t the instructions to the application form. 5) I have read and understood the warning on page one of x Applicant's Legal Signature - age 16 and older if applicable Name of courier company ( ) Facility ID Number x Mother/Father/Parent/Legal Guardian's Signature (if identifying minor) Facility Name/Location Agent ID Number x (if identifying minor) Mother/Father/Parent/Legal Guardian's Signature Signature of person authorized to accept applications Date Bk Card EF Execution Postage Other For Issuing Office Only * DS 11 C 09 2013 1 * Page 1 of 2 DS-11 06-2016

6 (Last, First, & Middle) Name of Applicant (mm/dd/yyyy) Date of Birth 10. Parental Information (at Parent's Birth) Last Name Mother/Father/Parent - First & Middle Name Place of Birth Date of Birth (mm/dd/yyyy) Sex U.S. Citizen? Male Yes - - Female No Mother/Father/Parent - First & Middle Name (at Parent's Birth) Last Name Date of Birth Place of Birth (mm/dd/yyyy) U.S. Citizen? Sex Yes Male - - No Female If yes, complete the remaining items in #11. 11. Have you ever been married? Yes No Place of Birth Full Name of Current Spouse or Most Recent Spouse Date of Birth (mm/dd/yyyy) - - Date of Marriage Have you ever been widowed or divorced? U.S. Citizen? Widow/Divorce Date No No Yes (mm/dd/yyyy) Yes (mm/dd/yyyy) (if applicable) (if age 16 or older) 13. Occupation 14. Employer or School 12. Additional Contact Phone Number Home Cell - - Work 18. Travel Plans 17. Eye Color 16. Hair Color 15. Height Countries to be Visited (mm/dd/yyyy) Return Date (mm/dd/yyyy) Departure Date if residence is different from Mailing Address. 19. Permanent Address - If P.O. Box is listed under Mailing Address or ) No P.O. Box Street/RFD # or URB ( Apartment/Unit City State Zip Code Provide the information of a person not traveling with you to be contacted in the event of an emergency. 20. Emergency Contact - Apartment/Unit Address: Street/RFD # or P.O. Box Name Relationship Phone Number Zip Code State City 21. Have you ever applied for or been issued a U.S. Passport Book or Passport Card? If yes, complete the remaining items in #21. Yes No Name as printed on your most recent passport book (mm/dd/yyyy) Most recent passport book issue date Most recent passport book number ) Stolen Lost In my possession (if expired Status of your most recent passport book: Submitting with application (mm/dd/yyyy) Most recent passport card issue date Most recent passport card number Name as printed on your most recent passport card Lost Submitting with application ) (if expired In my possession Stolen Status of your most recent passport card: LINE - FOR ISSUING OFFICE ONLY PLEASE DO NOT WRITE BELOW THIS Name as it appears on citizenship evidence Birth Certificate SR CR City Filed: Issued: Nat. / Citz. Cert. USCIS USDC Date/Place Acquired: A# Report of Birth Filed/Place: Passport C/R S/R Per PIERS #/DOI: Other: Attached: * DS 11 C 09 2013 2 * DS-5525 DS-64 P/C of Citz PAW DS-71 NPIC IRL Citz W/S P/C of ID DS-5520 DS-3053 Page 2 of 2 DS-11 06-2016

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