Important Reminders

☐
Your appointment is on Friday, Oct 05, 2018 at 10:00 - 11:00.
Please be at DFA NCR Northeast (Ali Mall) at least thirty (30) minutes before
your scheduled appointment.

☐ Please make sure you have prepared all the requirements.

☐
Be ready with both the original and photocopies of your documents when you
appear for personal appearance. Application processing may be delayed if
applicants are not ready with copies of their documents once inside the data
capturing site.

☐ For your NSO certificate requirements, you may call (02) 737-1111. Nationwide
delivery within 3-4 days.

☐
Kindly print your application form (with barcode) in A4-size paper.
You must have a printed application form to show and submit at your chosen
application site.
APPOINTMENT DETAILS: Republic of the Philippines WCS-RRR-LVJZ-PPT-DORev. October2015
DFA NCR Northeast (Ali DEPARTMENT OF FOREIGN AFFAIRS
Mall)
Friday, Oct 05, 2018
10:00 - 11:00
PASSPORT APPLICATION FORM
THISAPPLICATIONFORMIS NOT FORSALE. PLEASEDONOT LEAVEANY SPACES BLANK, INDICATE N/AIF NOT APPLICABLE. PROVIDINGFALSE
STATEMENTS INPASSPORT APPLICATIONSIS PUNISHABLE BY LAW(R.A. 8239).

_______________________________________
DATUR ___________________________________________
MICHAEL
LAST NAME/ APELYIDO FIRST NAME/ PANGALAN (Jr./II/III)
____________________________________________
FRANCISCO ________________________________________________
PHILIPPINES /BINANGONAN, RIZAL
MIDDLE NAME/ GITNANG PANGALAN PLACE OF BIRTH/ POOK NG KAPANGANAKAN

____________________
AUGUST / __________
12 / ___________
1979 GENDER/ KASARIAN □ MALE □ FEMALE
Month Day Year
DATE OF BIRTH/ PETSA NG KAPANGANAKAN
(Ex.: March8, 2010)

Civil Status: □ Single □ Married □ Widow/er □ Legally Separated □ Annulled

D
Complete Address: ROBINSON
________________________________________________________
ROAD, HONGKONG, AGUSAN DEL SUR Tel. No.:____________________
+09087891496
Present Occupation:OFW
_______________________________________________________ Mobile No.:_________________
+639087891496

I
Work Address: ____________________________________________________________
NONE Tel. No.:____________________
+85264891192
E-mail Address: CHELSSYCANDICEDATUR@GMAIL.COM
_______________________________________________________________________________________
Name of Wife / Husband: ALECIA
____________________________________________________
PE DATUR Citizenship:PHL
_________________
Name of Father: NONITO
___________________________________________________________
ARENA DATUR Citizenship:PHL
_________________
Maiden/ Single name of Mother:FELINA
______________________________________________
CARBAQUEL FRANCISCO Citizenship:PHL
_________________

A
Citizenship Acquired By:
□ Birth □ Election □ Marriage □ Naturalization □ R.A. 9225 □ Others _______________________
Are you a holder of a foreign passport? □ Yes □ No Have you ever been issued a Philippine Passport? □ Yes □ No
If Yes, from what country?___________________ If Yes, latest Passport Number? _______________________

P
Date of issue: _________________ Place of issue: __________
(For applicants below 18 years old ONLY)
Name of minor’s travelling companion: ________________________________________________________________
Companion’s relationship: _________________________ Contact Number: __________________________________

I SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided in this application are true and
correct. 3) The supporting documents attached are authentic. 4) I am aware that under the law, I am allowed to hold only one
Philippine passport at any given time. 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)

ORGAN DONATION (Optional)

In case of death, I hereby donate [ ] Any organ / tissue [x ] Specific organ N/A
____________________ to save other people.
Please immediately notify my family at mobile / tel. no. ALECIA
___________________________.
PE DATUR/ +8526489119…

FOR USE OF THE DEPARTMENT OF FOREIGN AFFAIRSONLY. PLEASE DO NOT WRITE BELOWTHIS LINE.

REMARKS:

Processor: Encoder: Signing Officer: Transmission Officer:

RECEIVEDCANCELLED PASSPORT: RECEIVEDNEWPASSPORT:
FOR ADMINISTRATIVE USE ONLY:

E-Receipt No: 1800413597 For moredetailsplease visit www.dfa.gov.phor www.passport.gov.ph

 Republic of the Philippines
DEPARTMENT OF FOREIGN AFFAIRS

ELECTRONIC RECEIPT NO. 1800413597

PAYMENT DETAILS:
MERCHANT: BAYD
BRANCH CODE: 1319
REFERENCE NO: DFUVYFTWW8
DATE: 10-August-2018
TIME: 12:11:10 PM

APPOINTMENT NUMBER: 00072018100500573

NAME: MICHAEL DATUR

TRANSACTION:
OPY
SITE NAME: DFA NCR NORTHEAST (ALI MALL)
PASSPORT PROCESSING

FA C
PROCESSING TYPE: REGULAR
MODE OF PAYMENT: CASH

AMOUNT
D
SERVICE NUMBER: 1800413597
(E-PASSPORT FEE) P950.00
(EXPEDITE FEE) P 0.00
 Republic of the Philippines
DEPARTMENT OF FOREIGN AFFAIRS

ELECTRONIC RECEIPT NO. 1800413597

PAYMENT DETAILS:
MERCHANT: BAYD
BRANCH CODE: 1319
REFERENCE NO: DFUVYFTWW8
DATE: 10-August-2018
TIME: 12:11:10 PM

APPOINTMENT NUMBER: 00072018100500573

NAME: MICHAEL DATUR

A NT
SITE NAME: DFA NCR NORTHEAST (ALI MALL)
TRANSACTION:

PLIC
PASSPORT PROCESSING

Y
PROCESSING TYPE: REGULAR

P
A CO P
MODE OF PAYMENT: CASH
SERVICE NUMBER: 1800413597
(E-PASSPORT FEE) P950.00
AMOUNT
(EXPEDITE FEE) P 0.00