Republic of the Philippines

LEAVE THIS BLANK

JVBL-APCE-LVJZ-PPT-DO Rev. July 2012

DEPARTMENT OF FOREIGN AFFAIRS

PHILIPPINE CONSULATE GENERAL LOS ANGELES, CALIFORNIA

PASSPORT APPLICATION FORM

F
For Passport Processor

THIS APPLICATION FORM IS NOT FOR SALE. PLEASE DO NOT LEAVE ANY SPACES BLANK, INDICATE N/A IF NOT APPLICABLE.
PROVIDING FALSE STATEMENTS IN PASSPORT APPLICATIONS IS PUNISHABLE BY LAW (R.A. 8239).

LAST NAME / APELYIDO

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

MIDDLE NAME / GITNANG PANGALAN

PLACE OF BIRTH / POOK NG KAPANGANAKAN

_________________ / _________ / ________

Month
Day
Year
DATE OF BIRTH / PETSA NG KAPANGANAKAN
(Ex.: March 8, 2010)

GENDER / KASARIAN

Civil Status:

Single

Married

Widow/er

MALE

Legally Separated

FEMALE

Annulled

Complete
US
address:
Complete
US US
Address
Complete
USaddress:
: ______________________________________________
Complete
Address:
Tel. No.: __________________
Complete
US
address
Address
(Abroad)
______________________________________________
Present Occupation: _____________________________________________
Mobile No.: ________________
Work Address: _________________________________________________
Tel. No.: __________________
E-mail Address: ______________________________________________________________________________
Name of Wife / Husband: _________________________________________
Citizenship: _______________
Name of Father: ________________________________________________
Citizenship: _______________
Maiden
/
Single
name
of
Mother:
____________________________________
Citizenship: _______________
Mother'sMother's
Mother's
First
Name
First
Full
Name
and
name
Maiden
and
before
Maiden
Surname
marriage:
surname:
Mother's Full name before Marriage:
:
Citizenship Acquired By:
Birth

Election

Marriage

Naturalization

Are you a holder of a foreign passport? Yes No

If Yes, from what country?______________________

R.A. 9225

Others_____________

Have you ever been issued a Philippine Passport? Yes No

If Yes, latest Passport Number? _____________________

Date of issue: ___________ Place of issue: ________________

(For applicants below 18 years old ONLY)

Name of minors travelling companion: ______________________________________________________
Companions relationship: ______________________ Contact Number: __________________________
I SOLEMNLY SWEAR that:
I SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided in this application are
(1) I am a Filipino citizen.
(2) The information
I provided3)inThe
this application
true and correct.
true and correct.
supportingare
documents
attached are authentic. 4) I am aware that under the law, I am
Any errors in the provided information in the passport are my own fault and I shall be responsible for the fees for the replacement of my passport.
allowed to hold only one Philippine passport at any given time. 5) I am aware that making false statements in
(3) The supporting documents attached are authentic.
passport
application,
or forged
documents
in support
thereof
(4) I am aware
that under
the law, furnishing
I am allowedfalsified
to hold only
one Philippine
passport
at any given
time. are punishable by law.
(5) 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 or Legal Guardian (for minor applicants)

FOR USE OF THE PHILIPPINE EMBASSY / CONSULATE ONLY. PLEASE DO NOT WRITE BELOW THIS LINE.

REMARKS:

Processor:
Encoder:
RECEIVED CANCELLED PASSPORT:

Signing Officer:
Transmission Officer:
RECEIVED NEW PASSPORT:

FOR ADMINISTRATIVE USE ONLY:

Forcheck
moreour
details
please
visit www.philippinesusa.org
For more information please
website:
www.philippineconsulatela.org