Important Reminders

! Your appointment is on Tue, Apr 03, 2012 at 10:30 am.

Please be at DFA Aseana by 10:00 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 [email protected].

Thank you for using the DFA Passport Appointment System.
 REPUBLIC OF THE PHILIPPINES
DEPARTMENT OFTHE
REPUBLIC OF FOREIGN AFFAIRS
PHILIPPINES
MANILA
DEPARTMENT OF FOREIGN AFFAIRS
E-PASSPORT APPLICATION
MANILA
E-PASSPORT APPLICATION
Tue,INFORMATION
PLEASE PROVIDE CORRECT Apr 03, 2012AND
10:30
DOam
NOT LEAVE SPACES BLANK
REPUBLIC
PLEASE PROVIDE CORRECT OF THE PHILIPPINES
INFORMATION AND DO NOT LEAVE SPACES BLANK
DEPARTMENT OF FOREIGN AFFAIRS
LAST
YUMULNAME / APELYIDO MANILA FIRST NAME / PANGALAN (Jr. / II / III)
REGIDOR
E-PASSPORT APPLICATION
LAST NAME / APELYIDO FIRST NAME / PANGALAN (Jr. / II / III)

PLEASE
MIDDLE PROVIDE
NAME / GITNANG
BAUTISTA CORRECTPANGALAN
INFORMATION AND DO NOT
PLACE
LEAVE
QUEZON OFSPACES
BIRTH / POOK
CITY BLANKNG KAPANGANAKAN
MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN

DATE
LAST OF BIRTH
MAY NAME
16, (Ex. Day/Month/Year)
/ APELYIDO
1966 GENDER / KASARIAN
FIRST NAME
MALE / PANGALAN (Jr. / II / III)
DATE OF BIRTH (Ex. Day/Month/Year) GENDER / KASARIAN
Civil Status: Ӂ Single Ӂ Married Ӂ Widow/er Ӂ Legally Separated Ӂ Annulled
Civil Status: Ӂ Single Ӂ
Name of Wife / Husband: X Married Ӂ Widow/er Ӂ Legally SeparatedCitizenship:
Ӂ Annulled
MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN
Name of Wife
Complete / Husband: 17-A AGUILAR ST.,S.F.D.M., QUEZON CITY METRO MANILA
Address: Citizenship:
Tel. No: 9842300
Complete
Present Address:
Occupation: BUSINESSMAN Tel. No:No: 09333377282
Mobile
Present
DATEAddress:
Work OF
Occupation:
BIRTH (Ex. Day/Month/Year)
17-A AGUILAR ST.,S.F.D.M.,Q.C. GENDER / KASARIAN Mobile No:
Work Address:
Email Address: Civil Status: Ӂ Single Ӂ Married Ӂ Widow/er Ӂ Legally Separated
[email protected] Ӂ Annulled
Office No: 9842300
Email Address:
Name of Father:
Wife / Husband: PRISCILLA RUTH ZERRUDO YUMUL Office No: FILIPINO
Citizenship:
Maiden/Single
Name of Father:
Complete Name of ANICETO LAYUG YUMUL
Address: Citizenship:
Tel. No: FILIPINO
Citizenship:
Mother:
Maiden/Single Name of
Present Occupation: Mobile No:
Citizenship:
Mother: MARCELA ESPINO BAUTISTA FILIPINO
Citizenship
Work Acquired By:
Address: Purpose of Travel:
Ӂ Birth
Citizenship Ӂ Election
Acquired By: Ӂ Marriage Ӂ Naturalization Ӂ Tour of Travel:
Purpose Ӂ Seaman Ӂ Business Ӂ Migration
Email Address: Office No:
Ӂ
X R.A.9225
Birth Ӂ Others:
Election ________________________
Ӂ Marriage Ӂ Naturalization Ӂ
X Study
Tour Ӂ Work
Seaman Ӂ Others:
Business______________
Ӂ Migration
Name of Father: Citizenship:
Ӂ R.A.9225 Ӂ Others: ________________________ Ӂ Study Ӂ Work Ӂ Others: ______________
Maiden/Single Name of
Are you a holder of a foreign passport? Citizenship:
Have you ever been issued a Philippine Passport?
Mother:
Are you a holder of a foreign passport? Ӂ Yes Ӂ No Ӂ Yes Ӂ No
Have you ever been issued a Philippine Passport?
Citizenship Acquired By: Purpose of Travel:
If Yes, from what country? ___________________
Ӂ Yes Ӂ X No If Yes, latest passport number? _______________
ӁX Yes Ӂ No
Ӂ Birth Ӂ Election Ӂ Marriage Ӂ Naturalization Ӂ Tour Ӂ Seaman Ӂ Business Ӂ Migration
If Yes, from what country? ___________________ kk846436
If Yes, latest passport number? _______________
Ӂ R.A.9225 Ӂ Others: ________________________ Ӂ
DateStudy Work
Ӂ ________
of issue Others:
ӁPlace ______________
of issue _________
Date of issue 01/23/2003 Manila
________ Place of issue _________
AreThis
youserves
a holder of a foreign
as Affidavit passport?
of Support and Consent to Travel Have you ever been issued a Philippine Passport?
This serves as Affidavit of Loss
(for Applicants below 18 years old ONLY)
Ӂ Yes Ӂ No Lost Passport Number: Ӂ Yes Ӂ No
This serves as Affidavit of Support and Consent to Travel This serves as Affidavit of Loss
Name of minor's
(for Applicants below 18 years old ONLY) Issued on:
If Yes, companion:
traveling from what country? ___________________ If Yes,
Lost latest
Passport passport number? _______________
Number:
Name of minor's Issued
Companion's Issued by:
on:
traveling companion:
Relationship: Date lost:
Date
Issued of
by: issue ________ Place of issue _________
Companion's
Address / Contact
Relationship: Date due
Lost lost:to:
Number:
Address
This/ serves
Contactas Affidavit of Support and Consent to Travel Lost due to: This serves as Affidavit of Loss
Number: (for Applicants below 18 years old ONLY) Lost Passport Number:
Name of minor's Issued on:
traveling companion:Signature of Parent or Legal Guardian Signature of Applicant
Issued by:
Companion's Signature of aParent or Legal Guardian Signature of Applicant
I SOLEMNLY
Relationship:SWEAR that 1) I am Filipino citizen. 2) The information I provided
Date lost: 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
I SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided
Address / Contact Lost due in this application is true and correct. 3) The supporting
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 ofSignature

Applicantof Applicant
IREMARKS:
SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided in thisSignature
application of Applicant
is true and correct. 3) The supporting
documents
REMARKS: 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 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: Signing Officer:
Processor: CANCELLED PASSPORT:Encoder:
RECEIVED RECEIVED NEWSigning
PASSPORT:
Signature Officer:
of Applicant
REMARKS: CANCELLED PASSPORT:
RECEIVED RECEIVED NEW PASSPORT:
FOR ADMINISTRATIVE USE ONLY:
FOR STRICT
ADMINISTRATIVE
COMPLIANCE:
USE Please
ONLY: print name and affix initials.

Processor: Encoder: Signing Officer:

RECEIVED CANCELLED PASSPORT: RECEIVED NEW PASSPORT:

FOR ADMINISTRATIVE USE ONLY:

 REPUBLIC OF THE PHILIPPINES
DEPARTMENT OFTHE
REPUBLIC OF FOREIGN AFFAIRS
PHILIPPINES
MANILA
DEPARTMENT OF FOREIGN AFFAIRS
E-PASSPORT APPLICATION
MANILA
E-PASSPORT APPLICATION
Tue,INFORMATION
PLEASE PROVIDE CORRECT Apr 03, 2012AND
10:30
DOam
NOT LEAVE SPACES BLANK
REPUBLIC
PLEASE PROVIDE CORRECT OF THE PHILIPPINES
INFORMATION AND DO NOT LEAVE SPACES BLANK
DEPARTMENT OF FOREIGN AFFAIRS
LAST
YUMULNAME / APELYIDO MANILA FIRST NAMERUTH
PRISCILLA / PANGALAN (Jr. / II / III)
E-PASSPORT APPLICATION
LAST NAME / APELYIDO FIRST NAME / PANGALAN (Jr. / II / III)

PLEASE
MIDDLE
ZERRUDOPROVIDE
NAME / GITNANG
CORRECTPANGALAN
INFORMATION AND DO NOT
PLACE
LEAVE
MANILA OFSPACES
BIRTH / POOK
BLANKNG KAPANGANAKAN
MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN

DATE
LAST OF BIRTH
OCT NAME
03, (Ex. Day/Month/Year)
/ APELYIDO
1965 GENDER / KASARIAN
FIRST NAME
FEMALE / PANGALAN (Jr. / II / III)
DATE OF BIRTH (Ex. Day/Month/Year) GENDER / KASARIAN
Civil Status: Ӂ Single Ӂ Married Ӂ Widow/er Ӂ Legally Separated Ӂ Annulled
Civil Status: Ӂ Single Ӂ
Name of Wife / Husband: X Married Ӂ Widow/er Ӂ Legally SeparatedCitizenship:
Ӂ Annulled
MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN
Name of Wife
Complete / Husband: 17-A AGUILAR ST.,S.F.D.M., QUEZON CITY METRO MANILA
Address: Citizenship:
Tel. No: 9842300
Complete
Present Address:
Occupation: BUSINESSWOMAN Tel. No:No: 09333377282
Mobile
Present
DATEAddress:
Work OF
Occupation:
BIRTH (Ex. Day/Month/Year)
5 MORQUECILLO ST.,S.F.D.M.,Q.C.GENDER / KASARIAN Mobile No:
Work Address:
Email Address: Civil Status: Ӂ Single Ӂ Married Ӂ Widow/er Ӂ Legally Separated
[email protected] Ӂ Annulled
Office No: 3710248
Email Address:
Name of Father:
Wife / Husband: REGIDOR BAUTISTA YUMUL Office No: FILIPINO
Citizenship:
Maiden/Single
Name of Father:
Complete Name of SALVADOR MAGALLANES ZERRUDO
Address: Citizenship:
Tel. No: FILIPINO
Citizenship:
Mother:
Maiden/Single Name of
Present Occupation: Mobile No:
Citizenship:
Mother: CONSOLACION TOLENTINO GAGARIN FILIPINO
Citizenship
Work Acquired By:
Address: Purpose of Travel:
Ӂ Birth
Citizenship Ӂ Election
Acquired By: Ӂ Marriage Ӂ Naturalization Ӂ Tour of
Purpose Ӂ Seaman
Travel: Ӂ Business Ӂ Migration
Email Address: Office No:
X R.A.9225
Ӂ Birth Ӂ Others:
Election ________________________
Ӂ Marriage Ӂ Naturalization Study
X Tour
Ӂ Work
Ӂ SeamanӁ Others:
Business______________
Ӂ Migration
Name of Father: Citizenship:
Ӂ R.A.9225 Ӂ Others: ________________________ Ӂ Study Ӂ Work Ӂ Others: ______________
Maiden/Single Name of
Are you a holder of a foreign passport? Citizenship:
Have you ever been issued a Philippine Passport?
Mother:
Are you a holder of a foreign passport? Ӂ Yes Ӂ No Ӂ Yes Ӂ No
Have you ever been issued a Philippine Passport?
Citizenship Acquired By: Purpose of Travel:
If Yes, from what country? ___________________
Ӂ Yes Ӂ X No If Yes, latest passport number? _______________
ӁX Yes Ӂ No
Ӂ Birth Ӂ Election Ӂ Marriage Ӂ Naturalization Ӂ Tour Ӂ Seaman Ӂ Business Ӂ Migration
If Yes, from what country? ___________________ uu 0206935
If Yes, latest passport number? _______________
Ӂ R.A.9225 Ӂ Others: ________________________ Ӂ
DateStudy Work
Ӂ ________
of issue Others:
ӁPlace ______________
of issue _________
Date of issue 11/17/2006 Manila
________ Place of issue _________
AreThis
youserves
a holder of a foreign
as Affidavit passport?
of Support and Consent to Travel Have you ever been issued a Philippine Passport?
This serves as Affidavit of Loss
(for Applicants below 18 years old ONLY)
Ӂ Yes Ӂ No Lost Passport Number: Ӂ Yes Ӂ No
This serves as Affidavit of Support and Consent to Travel This serves as Affidavit of Loss
Name of minor's
(for Applicants below 18 years old ONLY) Issued on:
If Yes, companion:
traveling from what country? ___________________ If Yes,
Lost latest
Passport passport number? _______________
Number:
Name of minor's Issued
Companion's Issued by:
on:
traveling companion:
Relationship: Date lost:
Date
Issued of
by: issue ________ Place of issue _________
Companion's
Address / Contact
Relationship: Date due
Lost lost:to:
Number:
Address
This/ serves
Contactas Affidavit of Support and Consent to Travel Lost due to: This serves as Affidavit of Loss
Number: (for Applicants below 18 years old ONLY) Lost Passport Number:
Name of minor's Issued on:
traveling companion:Signature of Parent or Legal Guardian Signature of Applicant
Issued by:
Companion's Signature of aParent or Legal Guardian Signature of Applicant
I SOLEMNLY
Relationship:SWEAR that 1) I am Filipino citizen. 2) The information I provided
Date lost: 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
I SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided
Address / Contact Lost due in this application is true and correct. 3) The supporting
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 ofSignature

Applicantof Applicant
IREMARKS:
SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided in thisSignature
application of Applicant
is true and correct. 3) The supporting
documents
REMARKS: 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 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: Signing Officer:
Processor: CANCELLED PASSPORT:Encoder:
RECEIVED RECEIVED NEWSigning
PASSPORT:
Signature Officer:
of Applicant
REMARKS: CANCELLED PASSPORT:
RECEIVED RECEIVED NEW PASSPORT:
FOR ADMINISTRATIVE USE ONLY:
FOR STRICT
ADMINISTRATIVE
COMPLIANCE:
USE Please
ONLY: print name and affix initials.

Processor: Encoder: Signing Officer:

RECEIVED CANCELLED PASSPORT: RECEIVED NEW PASSPORT:

FOR ADMINISTRATIVE USE ONLY:

 REPUBLIC OF THE PHILIPPINES
DEPARTMENT OFTHE
REPUBLIC OF FOREIGN AFFAIRS
PHILIPPINES
MANILA
DEPARTMENT OF FOREIGN AFFAIRS
E-PASSPORT APPLICATION
MANILA
E-PASSPORT APPLICATION
Tue,INFORMATION
PLEASE PROVIDE CORRECT Apr 03, 2012AND
10:30
DOam
NOT LEAVE SPACES BLANK
REPUBLIC
PLEASE PROVIDE CORRECT OF THE PHILIPPINES
INFORMATION AND DO NOT LEAVE SPACES BLANK
DEPARTMENT OF FOREIGN AFFAIRS
LAST
YUMULNAME / APELYIDO MANILA FIRST NAME
ANICE SALVI/ PANGALAN (Jr. / II / III)
E-PASSPORT APPLICATION
LAST NAME / APELYIDO FIRST NAME / PANGALAN (Jr. / II / III)

PLEASE
MIDDLE
ZERRUDOPROVIDE
NAME / GITNANG
CORRECTPANGALAN
INFORMATION AND DO NOT
PLACE
LEAVE
OFSPACES
KALLOCAN BIRTH
CITY/ POOK
BLANKNG KAPANGANAKAN
MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN

DATE
LAST OF BIRTH
NOV NAME
29, (Ex. Day/Month/Year)
/ APELYIDO
1991 GENDER / KASARIAN
FIRST NAME
FEMALE / PANGALAN (Jr. / II / III)
DATE OF BIRTH (Ex. Day/Month/Year) GENDER / KASARIAN
Civil Status: Ӂ Single Ӂ Married Ӂ Widow/er Ӂ Legally Separated Ӂ Annulled
Civil Status: Ӂ
Name of Wife / Husband: X Single Ӂ Married Ӂ Widow/er Ӂ Legally SeparatedCitizenship:
Ӂ Annulled
MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN
Name of Wife
Complete / Husband: 17-A AGUILAR ST.,S.F.D.M., QUEZON CITY METRO MANILA
Address: Citizenship:
Tel. No: 9842300
Complete
Present Address:
Occupation: STUDENT Tel. No:No: 09333377282
Mobile
Present
DATEAddress:
Work OF
Occupation:
BIRTH (Ex. Day/Month/Year)
17- A AGUILAR ST.,S.F.D.M.,Q.C.GENDER / KASARIAN Mobile No:
Work Address:
Email Address: Civil Status: Ӂ Single Ӂ Married Ӂ Widow/er Ӂ Legally Separated
[email protected] Ӂ Annulled
Office No: 9842300
Email Address:
Name of Father:
Wife / Husband: Office No:
Citizenship:
Maiden/Single
Name of Father:
Complete Name of REGIDOR BAUTISTA YUMUL
Address: Citizenship:
Tel. No: FILIPINO
Citizenship:
Mother:
Maiden/Single Name of
Present Occupation: Mobile No:
Citizenship: FILIPINO
Mother: PRISCILLA RUTH GAGARIN ZERRUDO
Citizenship
Work Address: Acquired By: Purpose of Travel:
Ӂ Birth
Citizenship Ӂ Election
Acquired By: Ӂ Marriage Ӂ Naturalization Ӂ Tour of Travel:
Purpose Ӂ Seaman Ӂ Business Ӂ Migration
Email Address: Office No:
Ӂ
X R.A.9225 Ӂ Election
Birth Others: ________________________
Ӂ Marriage Ӂ Naturalization Ӂ
X Study
Tour Ӂ Work
Seaman Ӂ Others:
Business______________
Ӂ Migration
Name of Father: Citizenship:
Ӂ R.A.9225 Ӂ Others: ________________________ Ӂ Study Ӂ Work Ӂ Others: ______________
Maiden/Single Name of
Are you a holder of a foreign passport? Citizenship:
Have you ever been issued a Philippine Passport?
Mother:
Are you a holder of a foreign passport? Ӂ Yes Ӂ No Ӂ Yes Ӂ No
Have you ever been issued a Philippine Passport?
Citizenship Acquired By: Purpose of Travel:
If Yes, from what country? ___________________
Ӂ Yes Ӂ X No If Yes, latest passport number? _______________
ӁX Yes Ӂ No
Ӂ Birth Ӂ Election Ӂ Marriage Ӂ Naturalization Ӂ Tour Ӂ Seaman Ӂ Business Ӂ Migration
If Yes, from what country? ___________________ mm 072463
If Yes, latest passport number? _______________
Ӂ R.A.9225 Ӂ Others: ________________________ Ӂ
DateStudy Work
Ӂ ________
of issue Others:
ӁPlace ______________
of issue _________
Date of issue 10/27/2003 Manila
________ Place of issue _________
AreThis
youserves
a holder of a foreign
as Affidavit passport?
of Support and Consent to Travel Have you ever been issued a Philippine Passport?
This serves as Affidavit of Loss
(for Applicants below 18 years old ONLY)
Ӂ Yes Ӂ No Lost Passport Number: Ӂ Yes Ӂ No
This serves as Affidavit of Support and Consent to Travel This serves as Affidavit of Loss
Name of minor's
(for Applicants below 18 years old ONLY) Issued on:
If Yes, companion:
traveling from what country? ___________________ If Yes,
Lost latest
Passport passport number? _______________
Number:
Name of minor's Issued
Companion's Issued by:
on:
traveling companion:
Relationship: Date lost:
Date
Issued of
by: issue ________ Place of issue _________
Companion's
Address / Contact
Relationship: Date due
Lost lost:to:
Number:
Address
This/ serves
Contactas Affidavit of Support and Consent to Travel Lost due to: This serves as Affidavit of Loss
Number: (for Applicants below 18 years old ONLY) Lost Passport Number:
Name of minor's Issued on:
traveling companion:Signature of Parent or Legal Guardian Signature of Applicant
Issued by:
Companion's Signature of aParent or Legal Guardian Signature of Applicant
I SOLEMNLY
Relationship:SWEAR that 1) I am Filipino citizen. 2) The information I provided
Date lost: 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
I SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided
Address / Contact Lost due in this application is true and correct. 3) The supporting
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 ofSignature

Applicantof Applicant
IREMARKS:
SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided in thisSignature
application of Applicant
is true and correct. 3) The supporting
documents
REMARKS: 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 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: Signing Officer:
Processor: CANCELLED PASSPORT:Encoder:
RECEIVED RECEIVED NEWSigning
PASSPORT:
Signature Officer:
of Applicant
REMARKS: CANCELLED PASSPORT:
RECEIVED RECEIVED NEW PASSPORT:
FOR ADMINISTRATIVE USE ONLY:
FOR STRICT
ADMINISTRATIVE
COMPLIANCE:
USE Please
ONLY: print name and affix initials.

Processor: Encoder: Signing Officer:

RECEIVED CANCELLED PASSPORT: RECEIVED NEW PASSPORT:

FOR ADMINISTRATIVE USE ONLY:

 REPUBLIC OF THE PHILIPPINES
DEPARTMENT OFTHE
REPUBLIC OF FOREIGN AFFAIRS
PHILIPPINES
MANILA
DEPARTMENT OF FOREIGN AFFAIRS
E-PASSPORT APPLICATION
MANILA
E-PASSPORT APPLICATION
Tue,INFORMATION
PLEASE PROVIDE CORRECT Apr 03, 2012AND
10:30
DOam
NOT LEAVE SPACES BLANK
REPUBLIC
PLEASE PROVIDE CORRECT OF THE PHILIPPINES
INFORMATION AND DO NOT LEAVE SPACES BLANK
DEPARTMENT OF FOREIGN AFFAIRS
LAST
YUMULNAME / APELYIDO MANILA FIRST NAME
AREGSH / PANGALAN (Jr. / II / III)
SYRILLE
E-PASSPORT APPLICATION
LAST NAME / APELYIDO FIRST NAME / PANGALAN (Jr. / II / III)

PLEASE
MIDDLE
ZERRUDOPROVIDE
NAME / GITNANG
CORRECTPANGALAN
INFORMATION AND DO NOT
PLACE
LEAVE
OFSPACES
KALOOCAN BIRTH
CITY/ POOK
BLANKNG KAPANGANAKAN
MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN

DATE
LAST OF 1994
BIRTH
NAME
SEP 07, (Ex. Day/Month/Year)
/ APELYIDO GENDER / KASARIAN
FIRST NAME
MALE / PANGALAN (Jr. / II / III)
DATE OF BIRTH (Ex. Day/Month/Year) GENDER / KASARIAN
Civil Status: Ӂ Single Ӂ Married Ӂ Widow/er Ӂ Legally Separated Ӂ Annulled
Civil Status: Ӂ
Name of Wife / Husband: X Single Ӂ Married Ӂ Widow/er Ӂ Legally SeparatedCitizenship:
Ӂ Annulled
MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN
Name of Wife
Complete / Husband: 17-A AGUILAR ST.,S.F.D.M., QUEZON CITY METRO MANILA
Address: Citizenship:
Tel. No: 9842300
Complete
Present Address:
Occupation: STUDENT Tel. No:No: 09333377282
Mobile
Present
DATEAddress:
Work OF
Occupation:
BIRTH (Ex. Day/Month/Year)
17-A AGUILAR ST.,S.F.D.M.,Q.C. GENDER / KASARIAN Mobile No:
Work Address:
Email Address: Civil Status: Ӂ Single Ӂ Married Ӂ Widow/er Ӂ Legally Separated
[email protected] Ӂ Annulled
Office No: 9842300
Email Address:
Name of Father:
Wife / Husband: Office No:
Citizenship:
Maiden/Single
Name of Father:
Complete Name of REGIDOR BAUTISTA YUMUL
Address: Citizenship:
Tel. No: FILIPINO
Citizenship:
Mother:
Maiden/Single Name of
Present Occupation: Mobile No:
Citizenship: FILIPINO
Mother: PRISCILLA RUTH GAGARIN ZERRUDO
Citizenship
Work Address: Acquired By: Purpose of Travel:
Ӂ Birth
Citizenship Ӂ Election
Acquired By: Ӂ Marriage Ӂ Naturalization Ӂ Tour of Travel:
Purpose Ӂ Seaman Ӂ Business Ӂ Migration
Email Address: Office No:
Ӂ
X R.A.9225 Ӂ Election
Birth Others: ________________________
Ӂ Marriage Ӂ Naturalization Ӂ
X Study
Tour Ӂ Work
Seaman Ӂ Others:
Business______________
Ӂ Migration
Name of Father: Citizenship:
Ӂ R.A.9225 Ӂ Others: ________________________ Ӂ Study Ӂ Work Ӂ Others: ______________
Maiden/Single Name of
Are you a holder of a foreign passport? Citizenship:
Have you ever been issued a Philippine Passport?
Mother:
Are you a holder of a foreign passport? Ӂ Yes Ӂ No Ӂ Yes Ӂ No
Have you ever been issued a Philippine Passport?
Citizenship Acquired By: Purpose of Travel:
If Yes, from what country? ___________________
Ӂ Yes Ӂ X No If Yes, latest passport number? _______________
ӁX Yes Ӂ No
Ӂ Birth Ӂ Election Ӂ Marriage Ӂ Naturalization Ӂ Tour Ӂ Seaman Ӂ Business Ӂ Migration
If Yes, from what country? ___________________ mm 072462
If Yes, latest passport number? _______________
Ӂ R.A.9225 Ӂ Others: ________________________ Ӂ
DateStudy Work
Ӂ ________
of issue Others:
ӁPlace ______________
of issue _________
Date of issue 10/27/2003 Manila
________ Place of issue _________
AreThis
youserves
a holder of a foreign
as Affidavit passport?
of Support and Consent to Travel Have you ever been issued a Philippine Passport?
This serves as Affidavit of Loss
(for Applicants below 18 years old ONLY)
Ӂ Yes Ӂ No Lost Passport Number: Ӂ Yes Ӂ No
This serves as Affidavit of Support and Consent to Travel This serves as Affidavit of Loss
Name of minor's
(for Applicants below 18 years old ONLY) Issued on:
If Yes, companion:
traveling from what country? ___________________ If Yes,
Lost latest
Passport passport number? _______________
Number:
Name of minor's Issued
Companion's Issued by:
on:
traveling companion:
Relationship: Date lost:
Date
Issued of
by: issue ________ Place of issue _________
Companion's
Address / Contact
Relationship: Date due
Lost lost:to:
Number:
Address
This/ serves
Contactas Affidavit of Support and Consent to Travel Lost due to: This serves as Affidavit of Loss
Number: (for Applicants below 18 years old ONLY) Lost Passport Number:
Name of minor's Issued on:
traveling companion:Signature of Parent or Legal Guardian Signature of Applicant
Issued by:
Companion's Signature of aParent or Legal Guardian Signature of Applicant
I SOLEMNLY
Relationship:SWEAR that 1) I am Filipino citizen. 2) The information I provided
Date lost: 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
I SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided
Address / Contact Lost due in this application is true and correct. 3) The supporting
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 ofSignature

Applicantof Applicant
IREMARKS:
SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided in thisSignature
application of Applicant
is true and correct. 3) The supporting
documents
REMARKS: 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 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: Signing Officer:
Processor: CANCELLED PASSPORT:Encoder:
RECEIVED RECEIVED NEWSigning
PASSPORT:
Signature Officer:
of Applicant
REMARKS: CANCELLED PASSPORT:
RECEIVED RECEIVED NEW PASSPORT:
FOR ADMINISTRATIVE USE ONLY:
FOR STRICT
ADMINISTRATIVE
COMPLIANCE:
USE Please
ONLY: print name and affix initials.

Processor: Encoder: Signing Officer:

RECEIVED CANCELLED PASSPORT: RECEIVED NEW PASSPORT:

FOR ADMINISTRATIVE USE ONLY:

 REPUBLIC OF THE PHILIPPINES
DEPARTMENT OFTHE
REPUBLIC OF FOREIGN AFFAIRS
PHILIPPINES
MANILA
DEPARTMENT OF FOREIGN AFFAIRS
E-PASSPORT APPLICATION
MANILA
E-PASSPORT APPLICATION
Tue,INFORMATION
PLEASE PROVIDE CORRECT Apr 03, 2012AND
10:30
DOam
NOT LEAVE SPACES BLANK
REPUBLIC
PLEASE PROVIDE CORRECT OF THE PHILIPPINES
INFORMATION AND DO NOT LEAVE SPACES BLANK
DEPARTMENT OF FOREIGN AFFAIRS
LAST
YUMULNAME / APELYIDO MANILA FIRST NAME
ANGEL / PANGALAN (Jr. / II / III)
SELENA
E-PASSPORT APPLICATION
LAST NAME / APELYIDO FIRST NAME / PANGALAN (Jr. / II / III)

PLEASE
MIDDLE
ZERRUDOPROVIDE
NAME / GITNANG
CORRECTPANGALAN
INFORMATION AND DO NOT
PLACE
LEAVE
OFSPACES
KALOOCAN BIRTH
CITY/ POOK
BLANKNG KAPANGANAKAN
MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN

DATE
LAST OF2002
BIRTH
NAME
JUL 23, (Ex. Day/Month/Year)
/ APELYIDO GENDER / KASARIAN
FIRST NAME
FEMALE / PANGALAN (Jr. / II / III)
DATE OF BIRTH (Ex. Day/Month/Year) GENDER / KASARIAN
Civil Status: Ӂ Single Ӂ Married Ӂ Widow/er Ӂ Legally Separated Ӂ Annulled
Civil Status: Ӂ
Name of Wife / Husband: X Single Ӂ Married Ӂ Widow/er Ӂ Legally SeparatedCitizenship:
Ӂ Annulled
MIDDLE NAME / GITNANG PANGALAN PLACE OF BIRTH / POOK NG KAPANGANAKAN
Name of Wife
Complete / Husband: 17-A AGUILAR ST.,S.F.D.M., QUEZON CITY METRO MANILA
Address: Citizenship:
Tel. No: 9842300
Complete
Present Address:
Occupation: STUDENT Tel. No:No: 09333377282
Mobile
Present
DATEAddress:
Work OF
Occupation:
BIRTH (Ex. Day/Month/Year)
17-A AGUILAR ST.,S.F.D.M.,Q.C. GENDER / KASARIAN Mobile No:
Work Address:
Email Address: Civil Status: Ӂ Single Ӂ Married Ӂ Widow/er Ӂ Legally Separated
[email protected] Ӂ Annulled
Office No: 9842300
Email Address:
Name of Father:
Wife / Husband: Office No:
Citizenship:
Maiden/Single
Name of Father:
Complete Name of REGIDOR BAUTISTA YUMUL
Address: Citizenship:
Tel. No: FILIPINO
Citizenship:
Mother:
Maiden/Single Name of
Present Occupation: Mobile No:
Citizenship: FILIPINO
Mother: PRISCILLA RUTH GAGARIN ZERRUDO
Citizenship
Work Address: Acquired By: Purpose of Travel:
Ӂ Birth
Citizenship Ӂ Election
Acquired By: Ӂ Marriage Ӂ Naturalization Ӂ Tour of Travel:
Purpose Ӂ Seaman Ӂ Business Ӂ Migration
Email Address: Office No:
Ӂ
X R.A.9225 Ӂ Election
Birth Others: ________________________
Ӂ Marriage Ӂ Naturalization Ӂ
X Study
Tour Ӂ Work
Seaman Ӂ Others:
Business______________
Ӂ Migration
Name of Father: Citizenship:
Ӂ R.A.9225 Ӂ Others: ________________________ Ӂ Study Ӂ Work Ӂ Others: ______________
Maiden/Single Name of
Are you a holder of a foreign passport? Citizenship:
Have you ever been issued a Philippine Passport?
Mother:
Are you a holder of a foreign passport? Ӂ Yes Ӂ No Ӂ Yes Ӂ No
Have you ever been issued a Philippine Passport?
Citizenship Acquired By: Purpose of Travel:
If Yes, from what country? ___________________
Ӂ Yes Ӂ X No If Yes, latest passport number? _______________
ӁX Yes Ӂ No
Ӂ Birth Ӂ Election Ӂ Marriage Ӂ Naturalization Ӂ Tour Ӂ Seaman Ӂ Business Ӂ Migration
If Yes, from what country? ___________________ mm 072461
If Yes, latest passport number? _______________
Ӂ R.A.9225 Ӂ Others: ________________________ Ӂ
DateStudy Work
Ӂ ________
of issue Others:
ӁPlace ______________
of issue _________
Date of issue 10/27/2003 Manila
________ Place of issue _________
AreThis
youserves
a holder of a foreign
as Affidavit passport?
of Support and Consent to Travel Have you ever been issued a Philippine Passport?
This serves as Affidavit of Loss
(for Applicants below 18 years old ONLY)
Ӂ Yes Ӂ No Lost Passport Number: Ӂ Yes Ӂ No
This serves as Affidavit of Support and Consent to Travel This serves as Affidavit of Loss
Name of minor's
(for Applicants below 18 years old ONLY) Issued on:
If Yes, companion:
traveling from what country? ___________________ If Yes,
Lost latest
Passport passport number? _______________
Number:
Name of minor's Issued
Companion's Issued by:
on:
traveling companion:
Relationship: Date lost:
Date
Issued of
by: issue ________ Place of issue _________
Companion's
Address / Contact
Relationship: Date due
Lost lost:to:
Number:
Address
This/ serves
Contactas Affidavit of Support and Consent to Travel Lost due to: This serves as Affidavit of Loss
Number: (for Applicants below 18 years old ONLY) Lost Passport Number:
Name of minor's Issued on:
traveling companion:Signature of Parent or Legal Guardian Signature of Applicant
Issued by:
Companion's Signature of aParent or Legal Guardian Signature of Applicant
I SOLEMNLY
Relationship:SWEAR that 1) I am Filipino citizen. 2) The information I provided
Date lost: 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
I SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided
Address / Contact Lost due in this application is true and correct. 3) The supporting
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 ofSignature

Applicantof Applicant
IREMARKS:
SOLEMNLY SWEAR that 1) I am a Filipino citizen. 2) The information I provided in thisSignature
application of Applicant
is true and correct. 3) The supporting
documents
REMARKS: 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 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: Signing Officer:
Processor: CANCELLED PASSPORT:Encoder:
RECEIVED RECEIVED NEWSigning
PASSPORT:
Signature Officer:
of Applicant
REMARKS: CANCELLED PASSPORT:
RECEIVED RECEIVED NEW PASSPORT:
FOR ADMINISTRATIVE USE ONLY:
FOR STRICT
ADMINISTRATIVE
COMPLIANCE:
USE Please
ONLY: print name and affix initials.

Processor: Encoder: Signing Officer:

RECEIVED CANCELLED PASSPORT: RECEIVED NEW PASSPORT:

FOR ADMINISTRATIVE USE ONLY: