U.S. passport application form, mostly illegible, with travel plans noted

U.S. Department of State
REGISTRATION U.S. PASSPORT APPLICATION FOR (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 End. I
COUNTRY / IN CARE OF (if applicable
	SOCIAL SECURITY NUMBER BIRTH

	OCCUPATION Jess WOWAN
	ZIP CODE STATE
	00 80 7 USUZ U.S. Citizen BIRTHPLACE BIRTHDATE MOTHER’S FULL MAIDEN NAME
14/FATHER’S FUI YOL MAXEL - No	Yes No KUNARD EIDIABELL
A CONTRA CARER STOUGH 16. HAVE YOU EVER R OH BEEN MARKED!	J.S. CITIZEN THOATE ATH LAG Yes No
7. WIDGWEDIVE DATE OF MOST RE ENT MARH 1983 Give Diets	OTHER NAMES YOU FILVE USED
(4) NO 18. HAVE YOU EVER BEEN ISSUED A U.S. PASSPORT? Yes	No AP YES, COMPLETE NEXT LINE AND SUBMIT PASSEPORT IF AVAILABLE. DISPOSITION
NAME IN WHICH ISSUED LASSESS PASSPORT NUMBER	APPROXIMATE ISSUE DATE Gubmitted Stoter 1998 01:44 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. 19. EMEFGENCY CONTACT, il you with, you may supply the name, address and teleghone number of a	20. TRAVEL PLANS (sot mandazory) Y add DWV Merrith
person not traveling with you tu be contactied in case of avergency. NAME	Clarke 20 3 20 al Trip Langth
STREET	10000 al Trip COUNTRIES TO BE MELLED
	Claited Kinsdo ZIP CODE TELEPHONE 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. 0 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 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) Clerk of Court; Location
	PASSPORT Agent SEAL
Signature of person authorized to	Postal Employee (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. 24. FOR ISSUING OFFICE US
Birth Certificate SH Passport Bearer’s Name
Report of Birth: Naturalization/Chiregahlp Ca
Other 1 Seen & Returned:
Arteched:	$0.00
FFF DS-11	OTHER Page 3 of 4 OMB No. 1405-0004 Expires: 12/31/2001 Estimated Burden - 20 Minutes

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U.S. passport application form, mostly illegible, with travel plans noted