DS-0011 Application Form PDF Download >> completed form ds-11 passport application

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False statements made knowingly and willfully in passport applications, including affidavits or other documents submi tted to support this application, are punishable by fine and/or imprisonment under U.S. law including the provisions of 18 U.S.C. 1001, 18 U.S. C. 1542, and/or 18 U.S.C. 1621. Alteration or mutilation of a passport issued pursuant to this application is punishable by fine and/or imprisonm ent under the provisions of 18 U.S.C. 1543. The use of a passport in violation of the restrictions contained herein or of the passport regul ations is punishable by fine and/or imprisonment under 18 U.S.C. 1544. All statements and documents are subject to verification. APPLICANTS WHO HAVE HAD A PREVIOUS U. S. PASSPORT BOOK AND/OR PASSPORT CARD  AS DIRECTED BY PUBLIC LAW 106-113 AND 22 CFR 51.28: To submit an application for a child under age 16 both parents or the child's legal guardian(s) must appear and present the following: - Evid ence of the child's U.S. citizenship; - Evid ence of the child's rela tionship to parents/guardian(s); AND - Origin al parental/guardian government-issued identification AND a photocopy of the front and back side of presented identification. IF ONLY ONE PARENT APPEARS, YOU MU ST ALSO SUBMIT ONE OF THE FOLLOWING: - Second pare nt's notarized written statement or DS-3053 (includi ng the child's full name and date of birth) consenting to the passport issuance for the child. The notarized statement cannot be more than three months old and must be signed and notarized on the same day, and must come with a photocopy of the front and back side of the second pa rent's government-issued photo identification; OR - Second pare nt’s death certificate if second parent is deceased; OR - Primary evide nce of sole authority to apply, such as a court order; OR - A w ritten statement or DS-5525 (made under penalty of perj ury) explaining in detail the second parent's unavailability.  A S DIRECTED BY REGULATION 22 C.F.R. 51.21 AND 51.28: - Each m inor child applying for a U.S. passport book and/or passport card must appear in person. REQUIREMENTS FOR CHILDREN FAILURE TO PROVIDE INFORMATION REQUESTED ON TH IS FORM, INCLUDING YOUR SOCIAL SECURITY NUMBER, MAY RESULT IN SIGNIFICANT PROCESSING DELAYS AND/OR THE DENIAL OF YOUR APPLICATION. FOR INFORMATION AND QUESTIONS Visit the official Department of State website at travel.state.gov or contact the National Passport Information Center (NPIC) via toll-free at 1-877-487-2778 (TDD: 1-888-874-7793) and [email protected] . Customer Service Representatives are available Monday-Friday 8:00a.m.-10:00p.m. Eastern Time (excluding federal holidays). Automated information is available 24 hours a day, 7 days a week. U.S. PASSPORT APPLICATION DS-11 06-2016 Instruction Page 1 of 4 WHAT TO SUBMIT WITH THIS FORM: 1. P ROOF OF U.S. CITIZENSHIP: Evidence of U.S. citizenship AND a photocopy of the front (and back, if there is printed information) must be submitted with your application. The photocopy must be on 8 ½ inch by 11 inch paper, black and white ink, legible, and clear. Eviden ce that is not damaged, altered, or f orged will be returned to you. Note: Lawful permanent resident cards submitted with this application will be forwarded to U.S. Citizenship and I mmigration Services, if we determine that you are a U.S. citizen. 2. PROOF OF IDENTITY: You must present your original identification AND submit a photoc opy of the front and back with your passport application. 3. R ECENT COLOR PHOTOGRAPH: Photograph must meet passport requirements – full fr ont view of the face and 2x2 inches in size. 4. F EES: Please visit our website at travel.state.gov for current fees. HOW TO SUBMIT THIS FORM: Complete and submit this application in person to a designated acceptance agent: a clerk of a federal or state court of record or a judge or clerk of a probate court accepting applications; a designated mu nicipal or county official; a designated postal employee at an authorized post off ice; an agent at a passport agency (by appointment only); or a U.S. cons ular official at a U.S. Embassy or Consul ate, if abroad. To find your nearest acce ptance facility, visit travel.state.gov or contact the National Passport Information Center at 1-877-487-2778. LOST OR STOLEN - If you cannot submit your valid or potentia lly valid U.S. passport book and/or passpor t card with this application and you have not previously submitted Form DS-64, Statement Regarding a Lost or Stolen U.S. Passport, you are required to fill out and submi t a DS-64 with this application. IN MY POSSESSION - If your most recent U.S.passport book and/or passport card was issued less than 15 years ago, and you were over the age of 16 at the time of issuance, you may be eligible to use Form DS-82 to renew your passport by mail. Follow the instructions on Page 2 for detailed information to completion and submission of this form. If you are 16 years of age or older : Your U.S. passport will be valid for 10 years from the date of issue except where limited by the Secretary of State to a shorter period. If you are under 16 years of age : Your U.S. passport will be valid for five years from the date of issue except where limited by the Secretary of State to a shorter period. PASSPORT VALIDITY LENGTH PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS  The passport application fee, security surcharge, and expedite fee may be paid in any of the following forms: Checks (personal, certified, or traveler's) with the applicant's full name and date of birth pr inted on the front; major credit card (Visa, Master Card, Americ an Express, and Discover); bank draft or cashier's check; money order (U.S. Postal, internatio nal, currency exchange), or if abroad, the foreign currency equiv alent, or a check drawn on a U.S. bank. All fees should be payable to the "U.S. Department of State " or if abroad, the appropriate U.S. Embassy or U.S. Consulate. When applying at a designated acceptance facility, the execution fee will be paid separately and should be made payable to the acceptance facility . NOTE: Some designated acceptance facilities do not accept credit cards as a form of payment.  For faster processing , you may request expedited service. Please include the expedite fee in your payment. Our website contains updated information regarding fees and processing times for expedited service. Ex pedited service is only available for passports mailed in the United States and Canada.  OVERNIG HT DELIVERY SERVICE is only ava ilable for passport book mailings in the United St ates. Please include the appropriate fee with your payment.  An additiona l fee will be charged when, upon your request, the U.S. Department of St ate verifies issuance of a previous U.S. passport or Consular Report of Birth Abroad because you are unable to submit evidence of U.S. citi zenship.  For applicants with U.S. government or military authorization for no-fee passports , no fees are charged except the execution fee when applying at a designated acceptance facility. PROOF OF U.S. CITIZENSHIP You may submit items such as the following containing your signa ture AND a photograph that is a good likeness of you: previous or current U.S. passport book; previous or current U.S. passport card; driver's license ( not temporary or learner's license); Certificate of Naturalizat ion; Certificate of Citizenship; military identification; or federal, state, or municipal government employee identification card . Temporary or altered document s are not a cceptable. You must establish your identity to the satisfaction of the ac ceptance agent and Passport Services. We may ask you to provide additional evidence to establish your identity. If you have changed your name, please see travel.state.gov for instructions. IF YOU CANNOT PROVIDE DOCUMENTARY EVIDENCE OF IDENTITY as stated above, you must appear with an IDENTIFYING WITNESS, who is a U .S. citizen, non-citizen U.S. national , or permanent resident alien that has known you for at least two years. Your witness must pr ove his or her identity and complete and sign an Affidavit of Identifying Witness (Form DS-71) before the acceptance agent. You must also submit some ident ification of your own. Submit a color photograph of you alone, sufficiently recent to be a good likeness of you (taken within the last six months), an d 2x2 inches in size. The image size measured from the bottom of your chin to the top of y our head (including ha ir) should not be less than 1 inch, and not more than 1 3/8 inches. The photograph must be in color, clear, with a full front view of your face. The photograph must be taken with a neutral facial exp ression (preferred) or a natural smile, and with both eyes open and be printed on photo quality paper with a plain light (white or off-white) background. The ph otograph must be taken in normal street attire, without a hat, or head covering unless a signed statement is submitted by the applicant verifying that th e hat or head covering is part of recognized, traditional religious attire that is customarily or required to be worn continuously when in public or a signed doc tor's statement is submitted verifying the item is used daily for medical purposes. Headphones, "bluetooth", or similar devices must not be worn in the pass port photograph. Glasses or other eyewear are not acceptable unless you provide a signed statem ent from a doctor explaining why you cannot remove them due to medical reasons (e.g., during the recovery period from eye surgery). Any photograph ret ouched so that your appearance is changed is unacceptable. A s napshot, most vending machine prints, hand-held self portraits, an d magazine or full-length photographs are unacceptable. A digital photo must meet the previously stated qualifications, and will be accepted for use at the discretion of Passport Services. Visit our website at travel.state.gov for details and information. FEES ARE LISTED ON OUR WEBSITE AT TRAVEL.STATE.GOV . BY LAW, THE PASSPORT FEES ARE NON-REFUNDABLE. DS-11 06-2016 PROOF OF IDENTITY COLOR PHOTOGRAPH FEES Instruction Page 2 of 4 APPLICANTS BORN IN THE UNITED STATES: Submit a previous U.S. passport or certified birth certificate. Passports th at are limited in validity will need to be supplemented by other evidence. A birth certificate must include your full name, date and place of birth, sex, date the birth record was filed, the seal or other certification of the official custodi an of such records (state, county, or ci ty/town office), and the full names of your parent(s). - If the birth certificate was filed more than 1 year after the birth : It must be supported by evidence described in the next paragraph. - If no birth record exists : Submit a registrar's notice to that effect. Also, submit a co mbination of the evidence listed below, which should include your given name and surname, date and/or place of birth, and the seal or other certification of the office (if customary), and the signat ure of the issuing official.   A hospital birth record;  An early baptism al or circumcision certificate;  Early ce nsus, school, medical, or family Bible records;  Insu rance files or published birth announc ements (such as a newspaper article); and  Notarized affidavits (or DS-10, Birth Affidavit) of older bl ood relatives having knowledge of your birth may be submitted in addition to some of the records listed abov e. A PPLICANTS BORN OUTSIDE THE UNITED STATES : Submit a previous U.S. passport, Certificate of Naturalization, Certificate of Citizenship, Consular Report of Birth Abroad, or evidence described below: - If you claim citiz enship through naturalization of parent(s) : Submit the Certificate(s) of Naturalization of y our parent(s), your foreign birth certificate (and official translation if the document is not in English), proof of your admission to the United States for permanent residence, and your parents' marriage/certificate and/or evidenc e that you were in the legal and physical custod y of your U.S. citizen parent, if applicable . - If you claim citizenship th rough birth abroad to at least one U.S. citizen parent : Submit a Consular Report of Birth (For m FS-240), Certification of Birth (Form DS-1350 or FS-545), or your foreign birth certificate (and offici al translation if the document is not in English), proof of U. S. citizenship of your parent, your parents' marriage certificate, and an affidavit showing all of your U.S. ci tizen parents' periods and places of residence/physical presence in the United States and abroad before your birth. - If yo u claim citizens hip through adoption by a U.S. citizen pare nt(s) : Submit evidence of your permanent re sidence status, full and final adoption , and your U.S. citizen parent(s) evidence of legal and physical custody. ( NOTE : Acquisition of U.S. citizenship for pers ons born abroad and adopted only applies if the applicant was born on or after 02/28/1983.) ADDITIONAL EVIDENCE: You must establish your citizenship to the satisfaction of the acceptance agent and Passport Services. We may ask you to provide additional evidence to establish your claim to U.S. citizenship. Visit travel.state.gov for details. DS-11 06-2016 FEDERAL TAX LAW Section 6039E of the Internal Revenue Code ( 26 U.S.C. 6039E) and 22 U.S.C 2714a(f) require you to provide your Social Security number (SSN), if you have one, when you apply for or renew a U.S. passport. If you have never been issued a SSN, you must enter zeros in box #5 of this form. If you are residing abroad, you must also provide the name of the fo reign country in which you are re siding. The U.S. Department of State must provide your SSN and foreign residence information to the U.S. Department of the Treasury. If you fail to provide the informat ion, your application may be denied and you are subject to a $500 penalty enforced by the IRS. All questions on this matter should be referred to th e nearest IRS office. If you send us a check, it will be converted into an electronic fu nds transfer (EFT). This means we will copy your check and u se the account information on it to electronically debit your account for the amount of the check. The debit from your account will usually o ccur within 24 hours and will be shown on your r egular account statement. You will not receive your original check back. We will destroy yo ur original check, but we will keep the copy of it. If the E FT cannot be processed for technical reasons, you authorize us to process the copy in place of your original che ck. If the EFT cannot be completed becaus e of insufficient funds, we may try to make the transfer up to two times, and we will charge you a one-time fee of $25, which we will also collec t by EFT. NOTICE TO CUSTOMERS APPLYING OUTS IDE A DEPARTMENT OF STATE FACILITY Passport service fees are established by law and regulation (see 22 U.S.C. 214, 22 C.F.R. 22.1, and 22 C.F.R. 51.50-56), and ar e collected at the time you apply for the passport service. If the Department fails to receive full payment of the applicable fees because, for e xample, your check is returned for any reason or you dispute a passport fee charge to your credit card, the U.S. Depart ment of State will take action to collect the delinquent fees from you under 22 C.F.R. Part 34, and the Federal Claims Collecti on Standards (see 31 C.F.R. Parts 900-904). I n accordance with the Debt Collection Improvement Act (Pub. L. 104-134), if the fees remain unpaid after 180 days and no repayment arrangements ha ve been made, the Department will refer the debt to the U.S. Department of Treasury for collect ion. Debt collection procedures used by U.S. Department of Treasury may include referral of the debt to private collection age ncies, reporting of the debt to credit bureaus, garnishment of private wages and administrative offset of the debt by reduci ng, or withholding eligible federal payments (e.g., tax refunds, social security pay ments, federal retirement, etc.) by the amount of your debt, including any interest penalti es or other costs incurred. In addition, non-payment of passpo rt fees may result in the invalidation of your passport. An inva lidated passport cannot be used for travel. FEE REMITTANCE USE OF SOCIAL SECURITY NUMBER For more information regarding reporting a lo st or stolen U.S. passport book or passport card (Form DS-64), or to determine you r eligibility for a passport renewal (Form DS-82), ca ll NPIC at 1-877- 487-2778 or visit travel.state.gov . Your Social Security number will be provi ded to U.S. Department of Treasury, used in connection with debt collection and checke d against lists of persons ineligible or potentially ineligible to receive a U.S. passport, among other authorized uses. PROTECT YOURSELF AGAINST IDENTITY THEFT! REPORT YOUR LOST OR STOLEN PASSPORT BOOK OR PASSPORT CARD! NOTICE TO APPLICANTS FOR OFFICIAL , DIPLOMATIC, OR NO-FEE PASSPORTS You may use this application if you meet all of the provisions listed on Instruction Page 2; howe ver, you must CONSULT YOUR SPO NSORING AGENCY FOR INSTRUCTIONS ON PROPER ROUTING PROCEDURES BEFORE FORWARDING THIS APPLICATION. Your completed passport will be released to your sponsor ing agency for forwarding to you. Passport Services will not mail a U.S. passport to a private addr ess outside the United States or Canada. If you do not live a t the address listed in the "mailing address", then you must put the name of the person and mark it as "In Care Of" in item # 8. If your mailing address c hanges prior to receipt of your new passport, please contact the Natio nal Passport Information Center. If you choose to provide your email address in Item #6 on this app lication, Passport Services may use that information to conta ct you in the event there is a problem with your application or if y ou need to provide information to us. You may receive your newly issued passport book and/ or card and your returned citizenship evidence in two separate mailings . If you are applying for both a U.S. passport book and passport card, you may receive three separate mailings ; one with your returned citizenship ev idence, one with your newly issued passport book, and one with your newly issued passport card. NOTICE TO U.S. PASSPORT CARD APPLICANTS The maximum number of letters provided for your given name (first and middle) on the U.S. passport card is 24 characters. The 24 characters may be shortened due to printing restrictions. If both your given name s are more than 24 characters, you must shorten one of your giv en names you list on item 1 of this form. U.S. passports, either in book or card format, are only issued to U.S. citizens or non-citizen U.S. nationals. Each person must obtain his or her own U.S. passport book or U.S. passport card. The passport card is a U.S. passport issued in card format. Like the traditional U.S. pass port book, it reflects the bearer's origin, identity, and nationality, and is subject to existing pass port laws and regulations. Unlike the U.S. passport book, the U.S. passport card is valid only for entry at land border crossings and sea ports of entry when traveling from Canada, Mexico, the Caribbean, and Ber muda. The U.S. passport card is not valid for international air travel. NOTE REGARDING MAILING OF YOUR PASSPORT(S) Instruction Page 3 of 4 DS-11 06-2016 ACTS OR CONDITIONS If any of the below-mentioned acts or conditions have been perfo rmed by or apply to the applicant, the portion which applies sh ould be lined out, and a supplementary explanatory statement under oath (or affirmat ion) by the applicant should be attached and made a part of th is application. I have not, since acquiring United States citi zenship/nationality, been naturalized as a citizen of a foreign state; taken an o ath or made an affirmation or other formal decl aration of allegiance to a forei gn state; entered or served in the armed forces of a foreign st ate; accepted or performed the duties of any office, post, or employment under the government of a fo reign state or political subdivision thereo f; made a formal renunciation of nationality either in the United States, or before a diplomatic or consular officer of the United States in a f oreign state; or been convicted by a court or court martial of competent jurisdicti on of committing any act of treas on against, or attempting by forc e to overthrow, or bearing arms against, the United States, or conspiring to overthro w, put down, or to destroy by force, the government of the Un ited States. Furthermore, I have not been convicted of a feder al or state drug offense or convicted of a "sex tourism" crimes statute, and I am not the subject of an outstanding federal, state, or local warran t of arrest for a felony; a criminal c ourt order forbidding my departure from the United States; a subpoena received from the United States in a matter involving feder al prosecution for, or grand jury investigation of, a felon y. PRIVACY ACT STATEMENT AUTHORITIES: Collection of this information is aut horized by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E , 22 U.S.C. 2714a(f), Section 236 of the Admiral James W. Nance and Meg Donovan Fore ign Relations Authorization Act, Fiscal Years 2000 and 2001; Exec utive Order 11295 (August 5, 1966); and 22 C.F.R. parts 50 and 51. PURPOSE: We are requesting this information in order to determine your eligibility to be issued a U.S. passport. Your Social Security number is used to verify your identity. ROUTINE USES: This information may be disclosed to another domestic governm ent agency, a private contractor, a foreign government agency, or to a private person or private employer in accordance with certain approved routi ne uses. These routine uses include, but a re not limited to, law enforcement activities, employment verifi cation, fraud prevention, border security, counterterrorism, litig ation activities, an d activities that meet the Secretary of State's responsibility to pr otect U.S. citizens and non- citizen nationals abroad. More information on the Routine Uses for the system can be found in System of Records Notices State-05, Overseas Citizen Services Records and St ate-26, Passport Records. DISCLOSURE: Providing information on this form is voluntary. Be advised, however, that failur e to provide the information requested on t his form may cause delays in processing your U.S. passport application and/or coul d result in the refusal or denial of your application. Failure to provide your Social Security number may result in the denial of your application (consistent with 22 U.S.C. 2714a(f) ) and may subject you to a penalty enforced by the Internal Revenue Service, as descri bed in the Federal Tax Law section of the instructions to this form. Your Social Security number will be provided to the Department of the Treasury and may be used in connection with debt collection, among ot her purposes authorized and generally described in this section. ELECTRONIC PASSPORT STATEMENT The U.S. Department of State now issues an "Electronic Passport" book, which contai ns an embedded electronic chip. The electro nic passport book continues to be proof of the bearer's U.S. citizenship/nationalit y and identity, and looks and functions in the same way as a passport without a chip. The addition of an electronic chip in the back cover enables the passport book to carry a duplicate electronic copy of a ll information from the data page. The electronic passport book is usable at all ports-o f-entry, including those that do not yet have electronic chip r eaders. Use of the electronic format provides the traveler the additional securi ty protections inherent in chip technology. Moreover, when used at ports-of-entry equipped with electroni c chip readers, the electronic passport book provides for faster clearance through some o f the port-of-entry processes. The electronic passport book does not require special handling or treatmen t, but like previous versi ons should be protected fro m extreme heat, bending, and from immersion in water. The electronic chip must be read using specially formatted readers, which protects the d ata on the chip from unauthorized reading. The cover of the electronic passport book is printed with a specia l symbol representing the embedded chip. The symbol will appear in port-of-entry areas w here the electronic passport book can be read. PAPERWORK REDUCTION ACT STATEMENT Public reporting burden for this collection of information is es timated to average 85 minutes per response, including the time required for searching existing data sources, gathering the necessary data, providing th e information and/or documents required, and reviewing the fin al collection. You do not have to supply this information unless this collection di splays a currently valid OMB control number. If you have comme nts on the accuracy of this burden estimate and/or recommendati ons for reducing it, please send them to: U. S. Department of State, Bureau of Consul ar Affairs, Passport Services, Office of Le gal Affairs and Law Enforcement Liaison, 44132 Mercur e Cir, P.O. Box 1227, Sterling, Virginia 20 166-1227 Instruction Page 4 of 4 4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.) APPLICATION FOR A U.S. PASSPORT DO NOT SIGN APPLICATION UNTIL REQUEST ED TO DO SO BY AUTHORIZED AGENT OM B CONTROL NO. 1405-0004 OMB EXPIRATION DATE: 10-31 -2019 E STIMATED BURDEN: 85 MIN Please Print Legibly Using Black Ink Only Attention: Read WARNING on page 1 of instructions Please select the document(s) for which you are applying: D ODep End. # Exp. First Middle - - MF A. B. DOTS 3. Sex STOP! CONTINUE TO PAGE 2 U.S. Passport Card U.S. Passport Book Note : The large book option is for those who frequently travel abroad during the passport validity period, and is recommended for applicants who have previously required the addition of visa pages. Large Book (Non-Standard) - - City Zip Code 6. Email (Info alerts offered at travel.state.gov ) @ 7. Primary Contact Phone Number - - 1. Name Last Country , if outside the United States State 9. List all other names you have used. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed) Addr ess Line 2: Clearly label Apartment, Company, Suite, Unit, Building, Floor, In Care Of or Attention if applicable. (e.g., In Care Of - Jane Doe, Apt # 100) x x Mother/Father/Parent/Legal Guardian's Signature (if identifying minor) x Mother/Father/Parent/Legal Guardian's Signature (if identifying minor) Applicant's Legal Signature - age 16 and older I declare under penalty of perjury all of the following: 1) I am a citizen or non-citizen nat ional of the United States and have not, since acquiring U.S. citizenship or nationality, performed any of the acts listed under "Acts or Conditions" on page four of the instruct ions of this application (unles s explanatory statement is attached); 2) the statements made on the application are true and correct; 3) I have not knowingly and willfully made false statement s or included false documents in support of this application; 4) t he photograph attached to this application is a genuine, current photograph of me; and 5) I have read and understood the warning on page one of the instructions to the application form. (Seal) Acceptance Agent (Vice) Consul USA Passport Staff Agent * DS 11 C 09 2013 1 * Bk Postage Execution Other EF For Issuing Office Only Date Facility Name/Location Identifying Documents - Applicant or Mother/Father/Parent on Second Signature Line (if identifying minor) DS-11 06-2016 Page 1 of 2 Facility ID Number Agent ID Number Signature of person authorized to accept applications Card Driver's License ID No Passport Military Other Country of Issuance State Issued ID Card Identifying Documents - Applicant or Mother/Father/Parent on Third Signature Line (if identifying minor) STAPLE 2" x 2" STAPLE STAPLE 2" x 2" STAPLE Attach a color photograph taken within the last six months Name Driver's License ID No Issue Date (mm/dd/yyyy) Exp. Date (mm/dd/yyyy) State of Issuance Passport Military Other 8. Mailing Address: Line 1: Street/RFD#, P.O. Box, or URB. 5. Social Security Number 2. Date of Birth (mm/dd/yyyy) Both Regular Book (Standard) The U.S. passport card is not valid for international air travel. For more information see page 1 of instructions. Country of Issuance State Issued ID Card Name Name of courier company ( if applicable ) Issue Date (mm/dd/yyyy) Exp. Date (mm/dd/yyyy) State of Issuance 18. Trav el Plans Departure Date (mm/dd/yyyy) Return Date (mm/dd/yyyy) Countries to be Visited Apartment/Unit 19. Perman ent Address - If P.O. Box is listed under Mailing Address or if residence is different from Mailing Address. Street/RFD # or URB ( No P.O. Box ) 13. O ccupation (if age 16 or older) 14. Em ployer or School (i f applicable) Home Cell Work 12. Ad ditional Contact Phone Number Mother/Father/Parent - First & Middle Name Last Name (at Parent's Birth) Date of Birth (mm/dd/yyyy) Place of Birth 10. Pa rental Information Male Female Yes No U.S. Citizen? Sex Date of Birth (mm/dd/yyyy) Name of Applicant (Last, First, & Middle) - - Mother/Father/Parent - First & Middle Name Last Name (at Parent's Birth) Date of Birth (mm/dd/yyyy) Place of Birth Male Female Yes No U.S. Citizen? Sex - - - - If yes, complete the remaining items in #11. Date of Marriage (mm/dd/yyyy) 11. H ave you ever been married? Full Name of Current Spouse or Most Recent Spouse Date of Birth (mm/dd/yyyy) Have you ever been widowed or divorced? Place of Birth Yes No Widow/Divorce Date (mm/dd/yyyy) Yes No Yes No U.S. Citizen? - - 15. He ight 16. Hair Color 17. Eye Color City Zip Code State 21. Ha ve you ever applied for or been issued a U.S. Passport Book or Passport Card? Name as printed on your most recent passport book Yes No If yes, complete the remaining items in #21. PLEASE DO NOT WRITE BELOW THIS LINE - FOR ISSUING OFFICE ONLY 20. Em ergency Contact - P rovide the information of a person not traveling with you to be contacted in the event of an emergency. Name Address: Street/RFD # or P.O. Box Apartment/Unit City State Zip Code Phone Number Relationship Name as printed on your most recent passport card Status of your most recent passport book: Submitting with application Stolen Lost In my possession (if expired ) Status of your most recent passport card: Submitting with application Stolen Lost In my possession (if expired ) Most recent passport book number Most recent passport book issue date (mm/dd/yyyy) Most recent passport card number Most recent passport card issue date (mm/dd/yyyy) * DS 11 C 09 2013 2 * DS-11 06-2016 Page 2 of 2 Name as it appears on citizenship evidence Birth Certificate SR CR City Filed: Issued: Passport C/R S/R Per PIERS #/DOI: Attached: P/C of ID DS-5520 DS-3053 DS-64 DS-5525 PAW DS-71 NPIC IRL Citz W/S Report of Birth Filed/Place: Nat. / Citz. Cert. USCIS USDC Date/Place Acquired: A# Other: P/C of Citz