| U.S. Department of State                                                                                                                                                                            |                                                                                                                                                                                                                         |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| REGISTRATION<br>U.S. PASSPORT<br>APPLICATION FOR<br>(Type or print all capital letters in blue of black ink in white areas only                                                                     |                                                                                                                                                                                                                         |
| 1, NAME (First and Middle                                                                                                                                                                           |                                                                                                                                                                                                                         |
| LAST                                                                                                                                                                                                |                                                                                                                                                                                                                         |
|                                                                                                                                                                                                     |                                                                                                                                                                                                                         |
| MAIL PASSPORT TO                                                                                                                                                                                    |                                                                                                                                                                                                                         |
|                                                                                                                                                                                                     | DP                                                                                                                                                                                                                      |
|                                                                                                                                                                                                     | Exp<br>End. I                                                                                                                                                                                                           |
| COUNTRY / IN CARE OF (if applicable                                                                                                                                                                 |                                                                                                                                                                                                                         |
|                                                                                                                                                                                                     | SOCIAL SECURITY NUMBER<br>BIRTH                                                                                                                                                                                         |
|                                                                                                                                                                                                     |                                                                                                                                                                                                                         |
|                                                                                                                                                                                                     | OCCUPATION<br>Jess WOWAN                                                                                                                                                                                                |
|                                                                                                                                                                                                     | ZIP CODE<br>STATE                                                                                                                                                                                                       |
|                                                                                                                                                                                                     | 00 80 7<br>USUZ<br>U.S. Citizen<br>BIRTHPLACE<br>BIRTHDATE<br>MOTHER'S FULL MAIDEN NAME                                                                                                                                 |
| 14/FATHER'S FUI<br>YOL<br>MAXEL<br>- No                                                                                                                                                             | Yes<br>No<br>KUNARD EIDIABELL                                                                                                                                                                                           |
| A<br>CONTRA<br>CARER STOUGH<br>16. HAVE YOU EVER<br>R OH<br>BEEN MARKED!                                                                                                                            | J.S. CITIZEN<br>THOATE<br>ATH<br>LAG<br>Yes<br>No                                                                                                                                                                       |
| 7.<br>WIDGWEDIVE<br>DATE OF MOST RE<br>ENT MARH<br>1983 Give Diets                                                                                                                                  | OTHER NAMES YOU FILVE USED                                                                                                                                                                                              |
| (4)<br>NO<br>18. HAVE YOU EVER BEEN ISSUED A U.S. PASSPORT?<br>Yes                                                                                                                                  | No AP YES, COMPLETE NEXT LINE AND SUBMIT PASSEPORT IF AVAILABLE.<br>DISPOSITION                                                                                                                                         |
| NAME IN WHICH ISSUED<br>LASSESS PASSPORT NUMBER                                                                                                                                                     | APPROXIMATE ISSUE DATE<br>Gubmitted<br>Stoter<br>1998<br>01:44<br>Lost                                                                                                                                                  |
|                                                                                                                                                                                                     | it is neuntary in sulmit a statement with an application to a new passure when a seesious valid possport envot be peasonse. The                                                                                         |
| atalament must set forth in detail why the previous passgort cannot be presented. Use Form DS-64.<br>19. EMEFGENCY CONTACT, il you with, you may supply the name, address and teleghone number of a | 20. TRAVEL PLANS (sot mandazory)<br>Y add<br>DWV<br>Merrith                                                                                                                                                             |
| person not traveling with you tu be contactied in case of avergency.<br>NAME                                                                                                                        | Clarke<br>20 3 20<br>al Trip<br>Langth                                                                                                                                                                                  |
| STREET                                                                                                                                                                                              | 10000<br>al Trip<br>COUNTRIES TO BE MELLED                                                                                                                                                                              |
|                                                                                                                                                                                                     | Claited Kinsdo<br>ZIP CODE<br>TELEPHONE<br>STATE                                                                                                                                                                        |
| CITY                                                                                                                                                                                                |                                                                                                                                                                                                                         |
| I have of since au juing Unite States                                                                                                                                                               | 21. STOP. DO NOT SICH APPLICATION UNTIL REQUESTED TO DO SO BY PERSON ADMINISTERING OATH.<br>0<br>tize alup perflamed iny of the sits listed under "Acts or Conditions * *                                               |
|                                                                                                                                                                                                     | on the liverse of this epolication form (Unlet explorier statisment is attache 1 willimniy swear lor affirmspa<br>that the statements inade of the application all the the phylogram allached is a true likeness of me. |
|                                                                                                                                                                                                     | Father's/Legal Guardian's Signature (if identifying minor)                                                                                                                                                              |
| ture - ace 14 or older                                                                                                                                                                              |                                                                                                                                                                                                                         |
|                                                                                                                                                                                                     | Mother's/Legal Guardian's Signature (if identifying minor)<br>Clerk of Court; Location                                                                                                                                  |
|                                                                                                                                                                                                     | PASSPORT Agent<br>SEAL                                                                                                                                                                                                  |
| Signature of person authorized to                                                                                                                                                                   | Postal Employee<br>(Vice) Consul USA                                                                                                                                                                                    |
| Applicant's or Father's Identifying Documents                                                                                                                                                       | Mother's Identifying Documents                                                                                                                                                                                          |
|                                                                                                                                                                                                     | BARSHI   Other ISSUESI                                                                                                                                                                                                  |
| chis aine                                                                                                                                                                                           | CIRIS                                                                                                                                                                                                                   |
| Applicant's evident of citize.<br>24. FOR ISSUING OFFICE US                                                                                                                                         |                                                                                                                                                                                                                         |
| Birth Certificate<br>SH<br>Passport Bearer's Name                                                                                                                                                   |                                                                                                                                                                                                                         |
| Report of Birth:<br>Naturalization/Chiregahlp Ca                                                                                                                                                    |                                                                                                                                                                                                                         |
| Other 1<br>Seen & Returned:                                                                                                                                                                         |                                                                                                                                                                                                                         |
| Arteched:                                                                                                                                                                                           | \$0.00                                                                                                                                                                                                                  |
| FFF<br>DS-11                                                                                                                                                                                        | OTHER<br>Page 3 of 4<br>OMB No. 1405-0004 Expires: 12/31/2001 Estimated Burden - 20 Minutes                                                                                                                             |