Form DS-11 Application for a US Passport

US DEPARTMENT OF STATE

OMB APPROVAL NO. 1405-0004
EXPIRATION DATE XX/XX/XXXX
ESTIMATED BURDEN: See Instruction Page 3

APPLICATION FOR A US PASSPORT
WARNING: False statements made knowingly and willfully in passport applications, including affidavits or
other supporting documents submitted therewith, are punishable by fine and/or imprisonment under the
provisions of 18 USC 1001, 18 USC 1542 , and/or 18 USC 1621. Alteration or mutilation of a passport issued
pursuant to this application is punishable by fine and/or imprisonment under the provisions of 18 USC 1543.
The use of a passport in violation of the restrictions contained therein or of the passport regulations is
punishable by fine and/or imprisonment under 18 USC 1544. All statements and documents are subject to
verification.

5 Yr.

When completing this form, PRINT IN BLUE OR BLACK INK ONLY.

R

1. Name of Applicant
Last

D

10 Yr.
O

Issue
Date
DP

End. #

Suffix (Jr., Sr., III)

Exp.

2. Date of Birth (mm/dd/yyyy)
First

Middle

3. Sex

4. Place of Birth

M

7. Height
Feet

6. Alien Registration No.

5. Social Security
Number

(City & State OR City & Country)

(If applicable)

F

8. Hair Color

9. Eye Color

10. Occupation

11. Employer

Inches

12. E-Mail Address (Optional)

13. Mailing Address
Apartment #

Street / RFD # OR Post Office Box
City

State

1 3/8”

From 1” to

2” x 2”

2” x 2”

Country

(If outside the US)

In Care of

(if applicable)

14. Permanent Address or Residence (If same as mailing address write “Same As Above”)
Street / RFD #

Apartment #

(DO NOT LIST P.O. BOX)

City
Submit two recent,
color photographs

Zip Code

State

Zip Code

15. Home Telephone (Include Area Code)

16. Business Telephone (Include Area Code)

(

(

)

17. Have you ever applied for or been issued a
YES
US passport?

If yes, complete the remaining items in block #17 and submit
most recent passport.

NO

Name in which your most recent passport was issued.

)

Status of most recent passport.
Submitted
Stolen
Lost

Other___________________

Approximate date your most recent US passport
was issued or date you applied. (mm/dd/yyyy)

Most recent passport number.

18. Travel Plans
Date of Trip (mm/dd/yyyy)

Length of Trip

19. Have you ever been married? YES

NO

Countries to be Visited

If yes, complete the remaining items in block #19.

Spouse’s or Former Spouse’s Full Name
Date of Birth

Place of Birth

Is your spouse (or former spouse) a US citizen?
YES
NO
Date of Most
Recent Marriage

Widowed?
Give Date:

Divorced?

20. What other names have you used? (Include name changes, maiden name, & former married names)
1)
DS-11
6/2005

2)

3)

4)
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NAME OF APPLICANT (Last, First, Middle)

Date of Birth (mm/dd/yyyy)

21. Parental Information
Mother’s Maiden Name
Last

First

First

Is your mother a US citizen?

Place of Birth

Date of Birth

Place of Birth

Middle

Father’s Name
Last

Date of Birth

Middle

YES

Is your father a US citizen?

NO

YES

NO

22. Emergency Contact—Provide the information of a person not traveling with you to be contacted in the event of an emergency.
Name

Street / RFD #
City

Apartment #
Telephone

(

State

)

STOP!

E-mail Address (Optional)

Zip Code
Relationship

DO NOT SIGN APPLICATION UNTIL REQUESTED TO DO SO BY PERSON ADMINISTERING OATH.

23. Oath & Signature
I declare under penalty of perjury that I am a United States citizen (or non-citizen national) and have not, since acquiring United States citizenship (or US
nationality), performed any of the acts listed under “Acts or Conditions” on the reverse of this application form (unless explanatory statement is attached). I
declare under penalty of perjury that the statements made on this application are true and correct.

Applicant’s or Father’s Identification information

X

Driver’s License

X

Issue Date

Type of Document

Applicant’s Signature—age 14 and older

Expiration Date

Passport

Mother’s/Legal Guardian’s Signature (if identifying

Military Identification

Place of Issue

Other (Specify)

X

Name

Father’s/Legal Guardian’s Signature (if identifying

FOR ACCEPTANCE AGENT USE ONLY
Facility Identification Number

ID Number
Mother’s Identification information
Type of Document
Driver’s License

Acceptance Agent; Facility Name & Location

Issue Date
Expiration Date

Passport
Military Identification

Place of Issue

Other (Specify)

(Vice) Consul USA; Location

Name
Passport Services’ Staff Agent

ID Number

Subscribed & sworn to (affirmed) before me
(SEAL)

Date
(Signature of person authorized to accept applications)

For Issuing Office Use Only
Name as it appears on citizenship evidence:
Birth Certificate:
Passport

SR

CR

City

File Date:

Issue Date:

Issue Date:

Report of Birth:

240 545 1350

Issue Date:

Naturalization Certificate

Issue Date:

Cert. #:

Citizenship Certificate

Issue Date:

Cert. #:

Other:

APPLICATION APPROVAL

Seen & Returned
Attached:
DS-11

FEE _________ EXEC. _________ EF _________ OTHER _________

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