Form no. *- ENGLISH

RENEWAL REGULAR PASSPORT APPLICATION FORM (Adult)

THIS FORM IS NOT FOR SALE

DEPARTMENT OF FOREIGN AFFAIRS

Office of Consular Affairs Last Revision: 07 October 2017 DEPARTMENT OF FOREIGN AFFAIRS

Office of Consular Affairs Last Revision: 07 October 2017 INSTRUCTIONS: Please PRINT entries legibly using black or blue ink only. Supply the necessary informa1on and indicate “N/A” for entries with no answers. Check boxes as appropriate.

CAPTURE SITE PRE-PROCESSING (Do not write on this part) APPOINTMENT VERIFICATION: REMARKS:

PASSPORT APPLICANT'S INFORMATION

1. LAST NAME SALAS

2. FIRST NAME ROMMEL

3. MIDDLE NAME OR MAIDEN LAST NAME DELOS REYES

4. GENDER

MALE

FEMALE

5. DATE OF BIRTH (EX. 01 JAN 2017)

16-JUL-1972

6. PLACE OF BIRTH

MANILA

7. CIVIL

STATUS

SINGLE

MARRIED

WIDOW/ER

ANNULLED

DIVORCED

8A. HOW DID YOU ACQUIRE PHL

CITIZENSHIP?

BY BIRTH

BY NATURALIZATION

BY RE-ACQUISITION(RA NO. 9225)

BY ELECTION

BY LEGISLATION

BY MARRIAGE

8B. DID YOU EVER LOSE YOUR PH

CITIZENSHIP? YES NO

8C. ARE YOU CURRENTLY A CITIZEN OF

ANOTHER COUNTRY? YES NO

8D. IF YES, FROM WHAT COUNTRY?

8E. HAVE YOU SERVED IN ANY FOREIGN

MILITARY? YES NO

8D. IF YES, WHAT COUNTRY?

APPLICANT'S CONTACT INFORMATION

9A. ADDRESS ABROAD

9B. ADDRESS IN THE PHILIPPINES

#3 APARTMENT ST.BAYANIHAN BACLARAN, PARAÑAQUE 1702, PHILIPPINES 10. TELEPHONE/MOBILE NUMBER 093*-***-****

11. EMAIL ADDRESS ad22uj@r.postjobfree.com

1

12. APPLICANT'S SPOUSE'S NAME: SALAS, SHIRLEY LLARANDO 13A. PERSON TO CONTACT IN CASE OF EMERGENCY: SALAS, SHERMEL MAPA 13B. TEL/MOBILE NO.: 092********

PARENTAL INFORMATION PARENTAL INFORMATION

14. FATHER'S DETAILS 15. MOTHER'S DETAILS 16A. PASSPORT NUMBER LAST NAME:

SALAS

LAST NAME:

DELOS REYES

EC3340844

FIRST NAME:

ROMEO

FIRST NAME:

CORAZON

16B. DATE OF ISSUE:

01-FEB-2015

MIDDLE NAME:

CALUGAY

MIDDLE NAME:

DE DIOS

16C. DATE OF EXPIRY:

CITIZENSHIP: (at time of

applicant's birth)

CITIZENSHIP: (at time of

applicant's birth)

16D. ISSUING AUTHORITY:

PHILIPPINES PHILIPPINES

STATUS OF CURRENT PASSPORT

19. PLEASE CHOOSE AS APPLICABLE:

PASSPORT INTACT

DAMAGED PASSPORT

Affidavit of Explanation

STATUS OF CURRENT PASSPORT

LOST VALID PASSPORT

Affidavit of Loss

Police Report in English

LOST EXPIRED PASSPORT

Affidavit of Explanation

DECLARATION OF APPLICANT

I HEREBY DECLARE AND AFFIRM that 1) I am a Filipino citizen. 2) The information provided in this application is true and correct. 3) The supporting documents attached are authentic. 4) I consent to the verification by the Philippine Government of the information I provided to establish my personal particulars, and further consent to its use for any lawful purpose. 5) I am aware that the information provided in this application will be treated in accordance with relevant privacy regulations. 6) I am aware that under the law, I am allowed to hold only one valid regular Philippine passport at a given time. 7) I am aware that making false statements in this passport application and furnishing falsified or forged documents are punishable by fine or imprisonment, and grounds for suspension or denial of application. 8) I understand and accept that the release of the passport could be subject to delay due to unforeseen events beyond the control of the Department of Foreign Affairs. 20. SIGNATURE OVER PRINTED NAME 21. DATE (EX. 01 JAN 2017) DO NOT WRITE BELOW THIS LINE. FOR THE DEPARTMENT’S USE ONLY. REMARKS: PASSPORT WATCHLIST

VERIFICATION:

RETURNED CANCELLED

PASSPORT: SIGNATURE

OF APPLICANT:

PROCESSOR'S SIGNATURE: ENCODER'S SIGNATURE:

OFFICIAL RECEIPT/PAYMENT SLIP NO.: DATE OF TRANSACTION: 2

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