LAST NAME

MIDDLE NAME

FIRST NAME

MALE FEMALEGENDER

PHILIPPINE CITIZENSHIP ACQUIRED BY

ELECTION

BIRTH

OTHERS

R.A. 9225 (DUAL CITIZENSHIP LAW)

NATURALIZATION

HAVE YOU EVER BEEN ISSUED A PHILIPPINE PASSPORT YES NO

IF YES, LATEST PASSPORT NUMBER

DATE OF ISSUE PLACE OF ISSUE

I SOLEMLY SWEAR that the attached photograph is mine, that the statements made on this application form are true and that the attached supporting documents are authentic.

For details, please visit www.philippinesusa.org

SIGNATURE OF APPLICANT

DATE OF BIRTH

PLACE OF BIRTH AGE

CIVIL STATUS

DISTINGUISHING MARK, IF ANY:

IMPORTANT: IF APPLICANT IS UNABLE TO APPLY IN PERSON, THIS FORM SHALL BE NOTARIZED.

SUBSCRIBED AND SWORN to before me this _ _ _ _ _ day of _ _ _ _ _ _ _ _ _ _ _ _ _ __ __ _ _ _ _ , 20 _ _ _ _ in _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.

NOTARY PUBLIC SEAL OF NOTARY PUBLIC

FOUR (4) 2x2 PHOTOS REQUIRED

Day Month Year

SINGLE MARRIED WIDOW/ER

NAME OF FATHER

NAME OF MOTHER

CITIZENSHIP

CITIZENSHIP

U.S. ADDRESS

PHILIPPINE ADDRESS

TELEPHONE NO.

REPUBLIC OF THE PHILIPPINES DEPARTMENT OF FOREIGN AFFAIRS

______________________________ Post

APPLICATION FOR TRAVEL DOCUMENT

MAIDEN

PLEASE PROVIDE CORRECT INFORMATION AND DO NOT LEAVE SPACES BLANK

/ /

NAME OF SPOUSE, IF MARRIED CITIZENSHIP

IF DIVORCED OR WIDOWED, NAME OF PREVIOUS SPOUSE

REASON FOR APPLYING A TRAVEL DOCUMENT

OCCUPATION

2x2 PHOTO