GP-s.orrars0 8173 REPUBLIC OF SOUTH AFRICA FOR OFFICIAL USE ONLY DEPARTMENT OF HOME AFFAIRS. UNINYANGO WEZANGAPHAKATHI BLOK {ves] NO DEPARTEMENT VAN BINNELANDSE SAKE DEPHATEMENTE YA MERERO YA TSA SELEGAE fcr sora : APPLICATION FOR A SOUTH AFRICAN PASSPORT OR TRAVEL DOCUMENT : UKUFAKA ISICELO SEPASIPOTI LASENINGIZIMU AFRIKA NOMA INCWADI YOKUHAMBa AMazwe | TPMT [_[ Ii “AANSOEK OWN SUID-AFRIKAANSE PASPOORT OF REISDOKUMENT KGOPELO VA GO GWETSA PASPOROTO GOBA LENGWALO LA MOSEPEDI Lost passport (ves| No lation or or Please consult page 3 regarang instructions and information APPLICATION FOR (mark which is applicable with an X) is cad acsson Docurent or Travel Puposes Oficial Pasoport Crew Member Ceca Emergency Passzon (Ceca) Child PassporfEndorement Masi Passport Diplomatic Passport Temporary Passpet ‘The document must be forwarded tomy adaross indicated bolow [|] A. PARTICULARS OF APPLICANT Simeme | Pea eee re eee tale dees epee an eh a An hae: declndicstechl dopehanil Prov sureme) Tt Marta Status: Unmaried [] Maries [] Whower [] wow [] Dhoreed Gender: Mae [_] Fema Date o bith Idety umber ee eee Comey aia ff Opa Cie eee: SE Sen a et i al aN AS SL peaeey Place of bitty pelea PD hd dk Leelee Postal Home Tel No re ee Work Te Ho a ee 1 1Gieidie: i 4 Call No. Phas a ee B._FOR OFFICIAL USE - CERTIFICATION OF PARTICULARS (PLEASE PRINT) |, (gummame and torenames intl) designation (rank) hereby cory that— (a) the applicant appeared before me and produced the folowing means of teeny, (b) me accompanying photos are a tue image ofthe applicant and have baen endorsed by me as prescribed; and (c) the thumbprint below has been taken by me and belongs ta the applicant (delete if not applicable —thurnbprnt required enly it applicant is 16 years and older) Date ] stones Officer o the Department of Home Airs Person authorised by the Deparment of Home Aas Adcress ‘SIGNATURE OF APPLICANT PHOTO OF APPLICANT LEFT THUMBPRINT OF APPLICANT / OF,C. CERTIFICATE OF CONSENT BY BOTH PARENTS OR GUARDIAN FOR A MINOR: BL73 {2} We, the undersigned, consent to tho issue of 2 pascport as applied for by my/our child (name of chit) Pere (8) Only a child witase birth has been registered in terms of the Birts and Doaths Rogistralion Act, 1992 (Act No.51 of 1992), may be issued with a passpor. ‘Signaie oF father (6) For purposes of passport a minor means any porson who has notyet stained the age of 1B years, excluding a person under TONE [ea sich one nny nome ee the sad age who — eee ee een (0) has been declared a major under the age of Majoiy Ac 1972 (Act No. 87 of 1872} () has contracted a legal marriage; or (i) Is legally emancipated, ‘Signature of mother (). Consent: Subject tothe exceptions below, minors requir Bones et ay aay \wten consent ofboth their parents or guarcians, as the case may be, before they may be granted passnors, The required (0) In the case of 2 foster cil writen consent by the parents or guarcians must be given in the prescribed manner in the space provided adjacent hereto. @ Exceptions: If one of the parents is deceased, this tact must be stated. Whare the consent is given by a guardian, the cumstances ol the quarfanship must slated asa result SSRN TET of spacial crcumstanaes (ta. the absence ofa parent, tis rot eee possible to complate the certizate, witton eansent in some ee citer form (2.9, aleter irom the absent parei) willbe accepted fs ae cia Ifa parent (or quarcian) refuses to give hisiher consent a competent court may order otherwise. The elevart cou order (2) Inthe case of quarianshi: ‘must aecompany the passport application in such an event. patents are dvoreed, both paves’ consent is required unioss { competent court orders otherwise. i @ parent or enather person haa bean granted sale guardianship by a competent Court the consent ofthe other parent or the parents wil not be Signature of guardian reco Dt een D. CITIZENSHIP (Must be completed by all applicants) (@) Have you acquired citizenship of another country on application? liso, state ‘COUNTRY PLACE OBTAINED. MEANS OF OBTAINING DATE l (0) Have travel tacts previously been issued to you? treo, when? | cee Passpon ‘document number L NOTE: South Alrican passports or other travol documents presently n the possession ofthe applicant must be presented with this application unless lost, stolon or damaged, In which case the applicant has to comply with rogulation 7 oF 13 of the Passports and ‘Travel Documents Regulations, 199. E, DECLARATION Da “i sevsonmnn hereby docare that the: Information furnishes above iso the best of my knowledge and beliet correct and | concur that i do not claim my passport wrthin throe (3) months from date of issue, my passport will be destroyed and| wilforet my fee. Date “Signature Place * (Signature ofthe applicant except whore a father, mother or guardian signs on behalf of hisiher minor child under the age of 16 years.) 2