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REPUBLIC OF THE PHILIPPINES

For inquiries.
DEPARTMENT OF FOREIGN AFFAIRS
MANILA
please call (02) 556 0000
or visit http://www.dfa.gov.ph 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) GENDER / KASARIAN: MALE FEMALE
PETSA NG KAPANGANAKAN

Civil Status: Single Married Widow/er Legally Separated Annulled


Name of Wife / Husband: ____________________________________________ Citizenship: ______________
First Name Middle Name Last Name
Complete Address: _________________________________________________ Tel. No.: ______________
Present Occupation: _________________________________________________ Mobile No.: ______________
Work Address: ____________________________________________________________________________
E-mail Address: __________________________________________________ Tel. No.: ______________
Name of Father: __________________________________________________ Citizenship: ______________
First Name Middle Name Last Name
Maiden/Single
Name of Mother: __________________________________________________ Citizenship: ______________
First Name Middle Name Last Name

Citizenship Acquired By: Purpose of Travel:


Birth Election Marriage Naturalization Tour Seaman Business Migration
R.A. 9225 Others _______________________ Study Work Others ____________

Are you a holder of a foreign passport? Yes No Have you ever been issued a Philippine Passport? Yes No
If Yes, Latest Passport Number? ______________________
If Yes, from what country? _______________________
Date of Issue: __________ Place of Issue: _____________

This serves as Affidavit of Support and Consent to Travel This serves as an Affidavit of Loss
(for Applicants below 18 years old ONLY)
Name of minor’s traveling Lost Passport Number: ___________________________
companion:
_________________________ Issued on: ______________ Issued by: ___________
Companion’s Relationship: _________________________ Date lost: __________________________________
Address / Contact Lost due to: __________________________________
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: Encoder: Signing Officer:

RECEIVED CANCELLED PASSPORT: RECEIVED NEW PASSPORT: