Important Reminders

! ! ! ! ! ! !

Your appointment is on Wed, Jul 04, 2012 at 11:30 am. Please be at DFA Aseana by 11:00 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 DEPARTMENT OFTHE FOREIGN AFFAIRS REPUBLIC OF PHILIPPINES MANILA DEPARTMENT OF FOREIGN AFFAIRS E-PASSPORT APPLICATION MANILA E-PASSPORT APPLICATION

Wed, Jul 04, 2012AND 11:30 am PLEASE PROVIDE CORRECT INFORMATION DO NOT LEAVE SPACES BLANK
REPUBLIC OF THE PHILIPPINES PLEASE PROVIDE CORRECT INFORMATION AND DO NOT LEAVE SPACES BLANK DEPARTMENT OF FOREIGN AFFAIRS MANILA LAST NAME / APELYIDO FIRST NAME / PANGALAN (Jr. / II / III) ROSIT JOAN E-PASSPORT APPLICATION LAST NAME / APELYIDO FIRST NAME / PANGALAN (Jr. / II / III) PLEASE MIDDLE NAME / GITNANG CORRECT PANGALAN INFORMATION AND DO NOT PLACE LEAVE OFSPACES BIRTH / POOK BLANK NG SUR KAPANGANAKAN SUAL PROVIDE CANTILAN,SURIGAO DEL MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN

DATE OF BIRTH (Ex. Day/Month/Year) GENDER / KASARIAN LAST NAME / APELYIDO FIRST NAME / PANGALAN (Jr. / II / III) 10/MAR/1984 FEMALE DATE OF BIRTH (Ex. Day/Month/Year) GENDER / KASARIAN Civil Status: Single Married Widow/er Legally Separated Annulled Civil Status: Single Annulled X Married Widow/er Legally Separated Name of Wife / Husband: Citizenship: MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN Name of Wife / Husband: #3 GEMINI ST.KRAUSE PARK SUBDIVISION,MOLINO 1,, CAVITE BACOOR Citizenship: Complete Address: Tel. No: 0464240699 Complete Address: Present Occupation: Tel. No: Mobile No: 09281818875 SEAFARER Present DATE OF Occupation: BIRTH (Ex. Day/Month/Year) / KASARIAN Mobile No: Work Address: MAGSAYSAY BUILDING. 520GENDER T.M KALAW ST. ERMITA, METRO MANILA Work Address: Civil Status: Single Married Widow/er Legally Separated Annulled Email Address: Office No: 026870888 ALEXANDRA_ANTONPH@YAHOO.COM Email Address: Office No: FILIPINO Name of Father: Wife / Husband: IAN WILLIAM PRADO YU Citizenship: Maiden/Single Name of JOSE ESTRADA ROSIT Name of Father: Citizenship: Complete Address: Tel. No: FILIPINO Citizenship: Mother: Maiden/Single Name of Present Occupation: ANTONIETA SUAL ROSIT Mother: Citizenship Acquired By: Work Address: Birth Election Citizenship Acquired By: Marriage Naturalization Email Address: R.A.9225 Others: Birth Election ________________________ X Marriage Naturalization Name of Father: R.A.9225 Others: ________________________ Maiden/Single Name of Are you a holder of a foreign passport? Mother: Are you a holder of a foreign passport? Yes No Citizenship Acquired By: If Yes, from what country? ___________________ Yes X No Birth Election Marriage Naturalization If Yes, from what country? ___________________ R.A.9225 Others: ________________________ AreThis youserves a holder of a foreign passport? as Affidavit of Support and Consent to Travel (for Applicants below 18 years old ONLY) Yes No This serves as Affidavit of Support and Consent to Travel Name of minor's (for Applicants below 18 years old ONLY) If Yes, companion: from what country? ___________________ traveling
Name of minor's Companion's traveling companion: Relationship: Companion's Address / Contact Relationship: Number: Address Contactas Affidavit of Support and Consent to Travel This/ serves Number: (for Applicants below 18 years old ONLY) Name of minor's traveling companion: Signature

Purpose of Tour of Purpose Study Tour

Business Migration Office No: Others: ______________ Business Migration Citizenship: Study Work Others: ______________ Citizenship: Have you ever been issued a Philippine Passport? Yes No Have you ever been issued a Philippine Passport? Purpose of Travel: If Yes, latest passport number? _______________ X Yes No Tour Seaman Business Migration UU065427 If Yes, latest passport number? _______________ Study ________ Work Others: ______________ Date of issue Place of issue _________

Travel: Seaman Travel: Work X Seaman

Mobile No: Citizenship: FILIPINO

CEBU CITY Date of issue 02/21/2007 ________ Place of issue _________ Have you ever been issued a Philippine Passport? This serves as Affidavit of Loss Lost Passport Number: Yes No This serves as Affidavit of Loss Issued on: Lost Passport Number: If Yes, latest passport number? _______________
Issued Issued by: on: Date lost: Issued by: issue Date of Date due Lost lost:to: Lost due to: This serves Lost Passport Number: Issued on:

________

Place of issue _________ as Affidavit of Loss

Issued by: Companion's Signature of a Parent or Legal Guardian Signature of Applicant I SOLEMNLY SWEAR that 1) I am Filipino citizen. 2) The information I provided Date lost: in this application is true and correct. 3) The supporting 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 Address / Contact SWEAR that 1) I am a Filipino citizen. 2) The information I provided in this application is true and correct. 3) The supporting Lost due allowed to hold only one Philippine passport at any given time. 6) I am aware that to: making false statements in passport application furnishing Number: 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 documents 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 Applicant Signature of Applicant

IREMARKS: SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided in thisSignature application of is true Applicant and correct. 3) The supporting 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: Processor: CANCELLED PASSPORT:Encoder: RECEIVED REMARKS: CANCELLED PASSPORT: RECEIVED FOR ADMINISTRATIVE USE ONLY:

Signing Officer:

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

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

RECEIVED CANCELLED PASSPORT: FORJun ADMINISTRATIVE USE ONLY: Thu, 28, 2012 03:44 pm 0fb430309e1f1b4f19714e85ca5ec37182e2c545