Important Reminders

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Your appointment is on Tue, Nov 15, 2011 at 10:30 am. Please be at DFA Aseana by 10:00 am.

Please make sure you have prepared all the requirements. You can view the list at www.passport.com.ph

Please make sure to photocopy all of your requirements. Applicants without a complete set of photocopies will not be entertained.

For your NSO certificate requirements, you may call (02) 737-1111. Nationwide delivery within 3-4 days.

You may have your passport delivered for extra convenience. Please prepare extra P120 for the delivery fee.

Please print this page and the application form on LONG BOND PAPER. Applicants without the printed application form will not be allowed entry at the DFA. Please complete the application form before going to the DFA.

For questions or concerns, you may email info@passport.com.ph. Thank you for using the DFA Passport Appointment System.

REPUBLIC OF THE PHILIPPINES DEPARTMENTOF THE PHILIPPINES REPUBLIC OF FOREIGN AFFAIRS DEPARTMENT MANILA OF FOREIGN AFFAIRS E-PASSPORT APPLICATION MANILA E-PASSPORT APPLICATION

Tue, Nov 15, 2011 10:30 NOT PLEASE PROVIDE CORRECT INFORMATION AND DOam LEAVE SPACES BLANK
REPUBLIC OF THE AND DO NOT PLEASE PROVIDE CORRECT INFORMATIONPHILIPPINES LEAVE SPACES BLANK DEPARTMENT OF FOREIGN AFFAIRS MANILA LAST NAME / APELYIDO FIRST NAME / PANGALAN (Jr. / II / III) MIRANDA ANGELA E-PASSPORT APPLICATION LAST NAME / APELYIDO FIRST NAME / PANGALAN (Jr. / II / III) PLEASE PROVIDE CORRECT INFORMATION AND DO NOT LEAVE SPACES POOK NG KAPANGANAKAN MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / BLANK PEREZ SORSOGON CITY MIDDLE NAME / GITNANG PANGALAN DATE 29, 1978 (Ex. Day/Month/Year) LAST NAME / APELYIDO SEP OF BIRTH DATE OF BIRTH (Ex. Day/Month/Year) Civil Status: Single PLACE OF BIRTH / POOK NG KAPANGANAKAN GENDER FIRST NAME / PANGALAN (Jr. / II / III) FEMALE / KASARIAN Married GENDER Legally Separated / KASARIAN Widow/er Annulled

Civil Married Widow/er Legally Separated Annulled Name of Wife / Husband: Status: X Single Citizenship: MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN Name of Wife / Husband: BLK 6E LOT 2 PH II #17 MAASIN ST. DELA COSTA II, NOVALICHES CALOOCAN CITY, CALOOCAN CITY CALOOCAN CITY Citizenship: 4733115 Complete Address: Tel. No: Complete Address: Present Occupation: Tel. No: Mobile No: 09065205810 RETAIL STORE MANAGER Present Occupation: Day/Month/Year)BLDG, 405 SEN. GIL PUYAT AVE. MAKATI CITY DATE OF BIRTH (Ex. 3/F URBAN GENDER / KASARIAN Mobile No: Work Address: Work Address: Civil Status: Single Married Widow/er Legally Separated Annulled Email Address: Office No: 8962755 ZGHINGMIRANDA@YAHOO.COM Email of Wife / Name Address: Husband: Father: Maiden/Single Name Name of Father: Complete Address: of JUANITO MORAL MIRANDA Mother: Maiden/Single Name Present Occupation: of ANA JERESANO PEREZ Mother: Citizenship Acquired By: Work Address: Birth Election Marriage Naturalization Citizenship Acquired By: Email Address: R.A.9225 Others: Election ________________________ Marriage Naturalization X Birth Name of Father: R.A.9225 Others: ________________________ Maiden/Single Name of Are you Mother: a holder of a foreign passport? Yes No Are you a holder of a foreign passport? Citizenship Acquired By: If Yes, from what country? ___________________ No Yes X Birth Election Marriage Naturalization If Yes, from what country? ___________________ R.A.9225 Others: ________________________ AreThis serves as Affidavit of Support and Consent to Travel you a holder of a foreign passport? (for Applicants below 18 years old ONLY) No This serves as Affidavit of Support and ConsentYes to Travel Name of minor's (for Applicants below 18 years old ONLY) If Yes, from what traveling companion: country? ___________________
Name of minor's Companion's traveling companion: Relationship: Companion's Address / Contact Relationship: Number: Address / serves as Affidavit of Support and Consent to Travel This Contact Number: (for Applicants below 18 years old ONLY) Name of minor's traveling companion: Signature

Office No: Citizenship: Citizenship: FILIPINO Tel. No: Citizenship: Mobile No: Citizenship: Purpose of Travel: Tour Seaman Purpose of Travel: Study Work Tour Seaman Study X Work

FILIPINO

Business Migration Office No: Others: ______________ Business Migration Citizenship: Others: ______________ Citizenship: Have you ever been issued a Philippine Passport? Yes Have you ever been issued a Philippine Passport? No Purpose of Travel: If Yes, latest passport number? _______________ No Yes X Tour Seaman Business Migration If Yes, latest passport number? _______________ Study Work Others: ______________ Date of issue ________ Place of issue _________ Date of issue ________ Place of issue _________ Have you ever been issuedAffidavit of Loss This serves as a Philippine Passport? Lost Passport Number: No This serves as Affidavit of Loss Yes Issued on: Lost Passport Number: If Yes, latest passport number? _______________
Issued by: Issued on: Date by: Issued of issue Datelost: Lost lost: Date due to: Lost due to: This serves Lost Passport Number: Issued on:

________

Place of issue _________ as Affidavit of Loss

Issued by: Companion's Signature of Parent citizen. 2) The information I provided in this application is true and correct. 3) The supporting Signature of Applicant I SOLEMNLY SWEAR that 1) I am a Filipino or Legal Guardian Date lost: Relationship:

of Parent or Legal Guardian

Signature of Applicant

documents attached are authentic. 4) I have not been issued a passport under any other name. 5) I am aware that under the law, I am I SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided to: this application is true and correct. 3) The supporting Address / Contact Lost that in allowed to hold only one Philippine passport at any given time. 6) I am aware due making false statements in passport application furnishing Number: documents attached are authentic. 4) I have not been issued a passport under any other name. 5) I am aware that under the law, I am falsified or forged documents in support thereof are punishable by law. allowed to hold only one Philippine passport at any given time. 6) I am aware that making false statements in passport application furnishing falsified or forged documents in support thereof are punishable by law.

Signature of Parent or Legal Guardian

Signature of Signature of Applicant Applicant

IREMARKS:SWEAR that 1) I am a Filipino citizen. 2) The information I provided in thisSignature of true and correct. 3) The supporting SOLEMNLY application is Applicant documents attached are authentic. 4) I have not been issued a passport under any other name. 5) I am aware that under the law, I am REMARKS: allowed to hold only one Philippine passport at any given time. 6) I am aware that making false statements in passport application furnishing FOR STRICT COMPLIANCE: Please print name and affix initials. falsified or forged documents in support thereof are punishable by law.

FOR STRICT COMPLIANCE: Please print name and affix initials. Processor: Encoder: RECEIVED Processor: CANCELLED PASSPORT:Encoder: REMARKS: RECEIVED CANCELLED PASSPORT: FOR ADMINISTRATIVE USE ONLY:

Signing Officer:

RECEIVED NEW PASSPORT: Signing Officer: Signature of Applicant RECEIVED NEW PASSPORT:

FOR ADMINISTRATIVE USE Please print name and affix initials. STRICT COMPLIANCE: ONLY: Processor: Encoder: Signing Officer: RECEIVED NEW PASSPORT:

RECEIVED CANCELLED PASSPORT: FOR ADMINISTRATIVE USE ONLY: