Important Reminders

☐
Your appointment is on Saturday, Sep 29, 2018 at 16:00 - 17:00.
Please be at Calasiao 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
Calasiao DEPARTMENT OF FOREIGN AFFAIRS
Saturday, Sep 29, 2018
16:00 - 17:00 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).

_______________________________________
FERNANDEZ ___________________________________________
ARRIANE KAY
LAST NAME/ APELYIDO FIRST NAME/ PANGALAN (Jr./II/III)
____________________________________________
CAMBA ________________________________________________
PHILIPPINES /DASOL, PANGASINAN
MIDDLE NAME/ GITNANG PANGALAN PLACE OF BIRTH/ POOK NG KAPANGANAKAN

____________________
OCTOBER / __________
11 / ___________
1994 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: 26
________________________________________________________
MENDOZA ST. POBLACION, DASOL, PANGASINAN, PANGASINAN, PA… Tel. No.:____________________
Present Occupation:TEACHER
_______________________________________________________ Mobile No.:_________________
+639076541267

I
Work Address: ____________________________________________________________
MALIMPIN DASOL PANGASINAN Tel. No.:____________________
+639189519497
E-mail Address: ARRIANEKAYFERNANDEZ@GMAIL.COM
_______________________________________________________________________________________
Name of Wife / Husband: ____________________________________________________ Citizenship: _________________
Name of Father: LUIS
___________________________________________________________
JR GUIANG FERNANDEZ Citizenship:PHL
_________________
Maiden/ Single name of Mother:NIDA
______________________________________________
CAMBA CAMBA 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. NIDA
___________________________.
CAMBA FERNANDEZ/ +63920…

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: 1800426076 For moredetailsplease visit www.dfa.gov.phor www.passport.gov.ph

 Republic of the Philippines
DEPARTMENT OF FOREIGN AFFAIRS

ELECTRONIC RECEIPT NO. 1800426076

PAYMENT DETAILS:
MERCHANT: ECPAY
BRANCH CODE: 71111991
REFERENCE NO: DFFIEXZVV2
DATE: 11-August-2018
TIME: 02:48:11 PM

APPOINTMENT NUMBER: 00162018092900190

NAME: ARRIANE KAY FERNANDEZ
SITE NAME: CALASIAO
TRANSACTION:
OPY
PASSPORT PROCESSING

FA C
PROCESSING TYPE: EXPRESS
MODE OF PAYMENT: CASH

AMOUNT
D
SERVICE NUMBER: 1800426076
(E-PASSPORT FEE) P 950.00
(EXPEDITE FEE) P 250.00
 Republic of the Philippines
DEPARTMENT OF FOREIGN AFFAIRS

ELECTRONIC RECEIPT NO. 1800426076

PAYMENT DETAILS:
MERCHANT: ECPAY
BRANCH CODE: 71111991
REFERENCE NO: DFFIEXZVV2
DATE: 11-August-2018
TIME: 02:48:11 PM

APPOINTMENT NUMBER: 00162018092900190

A N
SITE NAME: CALASIAOT
NAME: ARRIANE KAY FERNANDEZ

TRANSACTION:

PLICPASSPORT PROCESSING

Y
PROCESSING TYPE: EXPRESS

P
A CO P
MODE OF PAYMENT: CASH
SERVICE NUMBER: 1800426076
(E-PASSPORT FEE) P 950.00
AMOUNT
(EXPEDITE FEE) P 250.00