For inquiries. please call (02) 556 0000 or visit http://www.dfa.gov.ph REPUBLIC OF THE PHILIPPINES DEPARTMENT OF FOREIGN AFFAIRS MANILA E-PASSPORT APPLICATION NOT FOR SALE PLEASE PROVIDE CORRECT INFORMATION AND DO NOT LEAVE SPACES BLANK. _______________________________________________ _________________________________________________ LAST NAME / APELYIDO _______________________________________________ MIDDLE NAME / GITNANG PANGALAN ________________________________________________ FIRST NAME / PANGALAN (Jr. / II / III) _______________________________________________ PLACE OF BIRTH / POOK NG KAPANGANAKAN DATE OF BIRTH (Ex. 01-January-2000) PETSA NG KAPANGANAKAN GENDER / KASARIAN: MALE FEMALE Civil Status: Single First Name Married Widow/er Middle Name Legally Separated Last Name Annulled Name of Wife / Husband: ____________________________________________ Citizenship: ______________ Complete Address: _________________________________________________ Tel. No.: Present Occupation: _________________________________________________ Mobile No.: Work Address: E-mail Address: Name of Father: Maiden/Single Name of Mother: __________________________________________________ Tel. No.: First Name Middle Name Last Name ______________ ______________ ____________________________________________________________________________ ______________ __________________________________________________ Citizenship: ______________ __________________________________________________ Citizenship: ______________ First Name Middle Name Purpose of Travel: Marriage Naturalization Tour Study Seaman Work Business Others Migration Last Name Citizenship Acquired By: Birth R.A. 9225 Election Others _______________________ Yes No ____________ Yes No Are you a holder of a foreign passport? If Yes, from what country? Have you ever been issued a Philippine Passport? _______________________ If Yes, Latest Passport Number? ______________________ Date of Issue: __________ Place of Issue: _____________ This serves as an Affidavit of Loss Lost Passport Number: ___________________________ Issued on: ______________ Issued by: ___________ Date lost: Lost due to: This serves as Affidavit of Support and Consent to Travel (for Applicants below 18 years old ONLY) Name of minor’s traveling _________________________ companion: Companion’s Relationship: Address / Contact Number: _________________________ _________________________ ___________________________ Signature of Parent or Legal Guardian __________________________________ __________________________________ ___________________________ Signature of Applicant I SOLEMNY SWEAR that 1) I am a Filipino citizen. 2) The information I provided in this application is true and correct. 3) The supporting documents attached are authentic. 4) I have not been issued a passport under any other name. 5) I am aware that under the law, I am allowed to hold only one Philippine passport at any given time. 6) I am aware that making false statements in passport application furnishing falsified or forged documents in support thereof are punishable by law. ____________________________ Signature of Applicant REMARKS: FOR STRICT COMPLIANCE: Please print name and affix initials. Processor: RECEIVED CANCELLED PASSPORT: Encoder: Signing Officer: RECEIVED NEW PASSPORT: