Form no. *- ENGLISH

NEW REGULAR PASSPORT APPLICATION (Adult)

THIS FORM IS NOT FOR SALE

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 PALOMO JR

2. FIRST NAME ALFONSO

3. MIDDLE NAME OR MAIDEN LAST NAME SERVIÑAS

4. GENDER

MALE

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

06-MAY-1994

6. PLACE OF BIRTH

TRENTO ADS

7. CIVIL

STATUS

Singel

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

COACO BEACH PAMPANGA COACO BEACH PAMPANGA COACO BEACH PAMPANGA COACO BEACH PAMPANGA, DAVAO CITY 8000, PHILIPPINES

10. TELEPHONE/MOBILE NUMBER 095********

11. EMAIL ADDRESS ad3wwi@r.postjobfree.com

1

12. APPLICANT'S SPOUSE'S NAME:,

13A. PERSON TO CONTACT IN CASE OF EMERGENCY: ENRIQUEZ, MICHA PANES 13B. TEL/MOBILE NO.: 090********

PARENTAL INFORMATION

14. FATHER'S DETAILS 15. MOTHER'S DETAILS

First NAME: ALFONSO MIDDLE NAME:PALMES LAST NAME: PALOMO

FIRST NAME: EVANGELINE

MIDDLE NAME: PALMES MIDDLE NAME: SERVIÑAS

CITIZENSHIP: (at time of applicant's birth) CITIZENSHIP: (at time of applicant's birth) PHILIPPINES PHILIPPINES

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. 17. SIGNATURE OVER PRINTED NAME 18. DATE (EX. 01 JAN 2017) DO NOT WRITE BELOW THIS LINE. FOR THE DEPARTMENT’S USE ONLY. PROOF OF PHL CITIZENSHIP

BIRTH CERTIFICATE FROM PHL

STATISTICS AUTHORITY

CERTIFICATE OF

NATURALIZATION

IDENTIFICATION CERTIFICATE

OF CITIZENSHIP

ELECTION OF PHL CITIZENSHIP

OTHERS:

IDENTITY DOCUMENT

SUBMITTED

COMELEC VOTER'S ID

LTO DRIVER'S LICENSE

PROFESSIONAL REGULATORY

COMMISSION ID

UNIFIED MULTIPURPOSE ID

(UMID)

PWD ID

GSIS / SSS ID

SENIOR CITIZEN'S ID

OTHERS:

SUPPORTING DOCUMENTS

MARRIAGE CERTIFICATE FROM

PHL STATISTICS AUTHORITY

VOTER'S REGISTRATION

RECORD

COURT ORDER

NBI CLEARANCE

OTHERS:

REMARKS: PASSPORT WATCHLIST VERIFICATION:

PROCESSOR'S SIGNATURE: ENCODER'S SIGNATURE:

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

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