REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF FOREIGN AFFAIRS

MANILA
E-PASSPORT APPLICATION

PLEASE PROVIDE CORRECT INFORMATION AND DO NOT LEAVE SPACES BLANK

BALAGASAY JADE EFREN

LAST NAME / APELYIDO FIRST NAME / PANGALAN (Jr. / II / III)

MORRE QUEZON CITY

MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN

MAY 22, 1991 MALE

DATE OF BIRTH (Ex. Day/Month/Year) GENDER / KASARIAN
Civil Status: ☐
X Single ☐ Married ☐ Widow/er ☐ Legally Separated ☐ Annulled
Name of Wife / Husband: Citizenship:
Complete Address: Tel. No:
Present Occupation: Mobile No: 09063320970
Work Address:
Email Address: JADE_GEMINI_22@YAHOO.COM Office No:
Name of Father: GILDO DELMONTE BALAGASAY Citizenship:
Maiden/Single Name of
EULOGIA ESCALA MORRE Citizenship:
Mother:

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? Have you ever been issued a Philippine Passport?
☐ Yes ☐ No ☐ Yes ☐X No
If Yes, from what country? ___________________ If Yes, latest passport number? _______________

Date of issue ________ Place of issue _________

This serves as Affidavit of Support and Consent to Travel This serves as Affidavit of Loss
(for Applicants below 18 years old ONLY) Lost Passport Number:
Name of minor's Issued on:
traveling companion:
Issued by:
Companion's
Relationship: Date lost:
Address / Contact Lost due to:
Number:

Signature of Parent or Legal Guardian Signature of Applicant

I SOLEMNLY 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:

FOR ADMINISTRATIVE USE ONLY: