Republic of the Philippines LEAVE THIS BLANK …

1 JVBL-APCE-LVJZ-PPT-DO Rev. July 2012 LAST NAME / APELYIDOFIRST NAME / PANGALAN ( )MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN_____ / _____ / _____GENDER / KASARIAN MALE FEMALE Month Day YearDATE OF BIRTH / PETSA NG KAPANGANAKAN(Ex.: March 8, 2010)Civil Status: Single Married Widow/er Legally Separated AnnulledComplete Address: _____ Tel. No.: _____ (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: _____Citizenship Acquired By: Birth Election Marriage Naturalization 9225 Others_____Are you a holder of a foreign passport?

2 Yes No Have you ever been issued a philippine Passport? Yes NoIf Yes, from what country?_____ If Yes, latest Passport Number? _____ Date of issue: _____ Place of issue: _____Name of minor s travelling companion: _____Companion s relationship: _____ Contact Number: _____REMARKS:Processor: Encoder: Signing Officer: Transmission Officer:RECEIVED CANCELLED PASSPORT:RECEIVED NEW PASSPORT:FOR ADMINISTRATIVE USE ONLY:Signature of Applicant or Legal Guardian (for minor applicants)FOR USE OF THE philippine EMBASSY / CONSULATE ONLY. PLEASE DO NOT WRITE BELOW 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 ( 8239). Republic of the Philippines (For applicants below 18 years old ONLY)DEPARTMENT OF FOREIGN AFFAIRSPASSPORT APPLICATION FORM I SOLEMNLY SWEAR that 1) I am a Filipino citizen.

3 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 more details please visit SOLEMNLY SWEAR that:(1) I am a Filipino citizen. (2) The information I provided in this application are true and correct. 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. (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 more information please check our website: CONSULATE GENERAL LOS ANGELES, CALIFORNIAC omplete US addressComplete US address:Complete US address:Complete USAddressMother's First Name and Maiden Surname:Mother's First Name and Maiden surname:Complete US Address :Mother's Full name before marriage: LEAVE this BLANKFFor Passport ProcessorMother's Full name before Marriage.