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PHILIPPINE EMBASSY

KUALA LUMPUR, MALAYSIA


NOT FOR SALE
E-PASSPORT APPLICATION

PLEASE PROVIDE CORRECT INFORMATION AND DO NOT LEAVE SPACES BLANK

_____________________________________________ _________________________________________
LAST NAME / APELYIDO FIRST NAME / PANGALAN (Jr. / II / III)
_____________________________________________ _________________________________________
MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN
________ / ______________________ / ____________ GENDER / KASARIAN: MALE FEMALE
Day Month Year
DATE OF BIRTH / PETSA NG KAPANGANAKAN
(Ex. 01 January 2010)

Civil Status: Single Married Widow/er Legally Separated Annulled


Name of Wife / Husband: _______________________________________________ Citizenship: ______________
First Name Middle Name Last Name
Complete Address: __________________________________________________ Tel. No.: _______________
Present Occupation: ___________________________________________________ Mobile No.: ______________
Work Address: ______________________________________________________________________________
E-mail Address: __________________________________________________ Tel. No. ______________
Name of Father: __________________________________________________ Citizenship: ______________
First Name Middle Name Last Name
Maiden/Single
Name of Mother: __________________________________________________ Citizenship: ______________

Citizenship Acquired By: Purpose of Travel:


Birth Election Marriage Naturalization Tour Seaman Business Migration
Study Work Others ___________________

Are you a holder of a foreign passport? Yes No


Have you ever been issued a Philippine Passport? Yes No
If Yes, Latest Passport Number? _______________________________
If yes, from what country? __________________________________
Date of Issue: _______________ Place of Issue: _______________
This serves as Affidavit of Support and Consent yo Travel
This serves as an Affidavit of Loss
(for Applicants below 18 years old ONLY)
Name of minor’s travelling
Lost Passport No: ______________________________________
companion:
Issued on: ________________ Issued by: _________________
___________________________________
Date lost: ___________________________________________
Companion’s Relationship : ___________________________________
Lost due to: _________________________________________
Address / Contact
Number: ___________________________________
_______________________
____________________________________
Signature of Applicant
Signature of Parent or Legal Guardian
I SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided in this application is true 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 allowed to hold only one Philippine passport at any given time. 6) I am aware that making false statements in this passport
application furnishing falsified or forged documents in support thereof are punishable by law.

__________________________
Signature of Applicant

REMARKS:

FOR STRICT COMPLIANCE: Please print name and affix initials.


Processor: Encode: Signing Officer:
RECEIVED CANCELLED PASSPORT: RECEIVED NEW PASSPORT:

FOR ADMINISTRATIVE USE ONLY:

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