APPLICATION FORM FOR TRINIDAD AND TOBAGO PASSPORT - Ministry of Foreign ...

APPLICATION FORM FOR TRINIDAD AND TOBAGO PASSPORT (APPLICANTS 16 YEARS AND OVER)

DO NOT BEND OR FOLD

PLEASE PRINT INFORMATION IN BLOCK LETTERS USING DARK BLUE OR BLACK INK PEN

FOR OFFICIAL USE ONLY

WARNING TO ALL APPLICANTS AND RECOMMENDERS Any such person who makes a written or oral statement knowingly to be false

or misleading is guilty of an offence and is liable to fine and imprisonment.

PASSPORT TYPE

_________

ORIGIN

_____________ RECEIPT #

_______________ PASSPORT #

__________________

EXPEDITED

_________

PICK UP

_____________ DATE

_______________ DATE OF ISSUE _________________

PRE-PAID SHIPPING

____________

REASON FOR APPLICATION _____________

VALID TO

_________________

1. SURNAME

/_P__/_E__/_T__/_E__/_R__/_S__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

FIRST NAME

/__J_/_A__/_N__/_E__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

MIDDLE NAME(S) /_M__/_A__/_R__/_I__/_A__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

MAIDEN NAME FORMER NAME SURNAME

FIRST NAME

/_Z__/_A__/__C_/__K_/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

/_Z__/_A__/_C__/_K__/_-__/_D__/_O__/_E__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/ /__J_/_A__/_N__/_E__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

MOTHER'S MAIDEN NAME

SURNAME

/_J__/_A__/_M__/_E__/_S__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

FATHER'S FULL NAME

SURNAME

/_Z__/_A__/_C__/_K__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

FIRST NAME /_G__/_E__/_O__/_R__/_G__/_E__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

2. PERSONAL DATE OF BIRTH

INFORMATION___2_1___/___0_7___/_1_9_7__1__

SEX

MALE [ ]

FEMALE [X]

Day

Month Year

PLACE OF BIRTH /_S__/_A__/_N__/___/_F__/_E__/_R__/_N__/_A__/_N__/_D__/_O__/___/___/___/___/___/___/___/___/

TOWN /CITY

/_T__/_R__/__I_/_N__/__I _/_D__/_A__/_D__/___/_A__/_N__/_D__/___/_T__/_O__/_B__/_A__/_G__/_O__/___/

COUNTRY

HEIGHT (CM)

____1_5_6______ COLOUR OF EYES /_B__/_R__/_O__/_W__/_N__/___/___/___/___/___/

HAIR COLOUR /__B_/_L__/_A__/_C__/_K__/___/___/___/___/___/

MARITAL STATUS: SINGLE

[ ]

X MARRIED [ ]

WIDOWED [ ]

DIVORCED [ ]

PHOTOGRAPH

SEPARATED [ ] OCCUPATION / PROFESSION

OTHER [ ]

/_S__/_U__/_P__/_E__/_R__/_V__/__I_/__S_/__O_/_R__/___/___/___/___/___/___/___/___/___/___/___/___/

HOME ADDRESS

/_1__/_1__/_1__/_2__/___/__I_/_N__/_D__/_U__/_S__/_T__/_R__/_Y__/___/_L__/_A__/_N__/_E__/_,__/_R__/_O__/_C__/_K__/_V__/_I__/_L__/_L__/_E__/___/___/___/

Street Name

Town/ City

/___/_M__/_D__/___/___/___/___/___/___/___/___/___/___/_1__/_0__/__0_/_2__/_3__/___/___/___/___/_U__/_S__/_A__/___/___/___/___/___/___/

Town /City

Zip Code

Country

MAILING ADDRESS (IF DIFFERENT FROM HOME ADDRESS)

/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

Street Name

Town/ City

/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

Town /City

Zip Code

Country

WORK ADDRESS, OR IF RESIDENT ABROAD, LOCAL ADDRESS

/_1__/_0__/_0__/___/_M__/_A__/_I__/_D__/_E__/_N__/___/_L__/_A__/_N__/_E__/,___/_L__/_A__/_U__/_R__/_E__/_L__/___/___/___/___/___/___/___/___/___/

/___/_M__/_D__/___/__S_tr/e_et_N_a/_m_e_/___/___/___/___/___/___/_2__/_0__/_1__/_0__/_3__/___/___/_T_o_w/n_/ _C_it/y_U__/__S_/_A__/___/___/___/___/___/___/

Town /City

Zip Code

Country

NAME OF FIRM / ORGANIZATION

/__S_/_T_._/___/_J__/_A__/_M__/_E__/_S__/___/_S__/_E__/_C__/_O__/_N__/_D__/_A__/_R__/_Y__/___/___/___/___/___/___/___/___/___/___/___/___/___/

HOME TEL. NO. /_3__/_0__/__1_/_-__/_2__/_4__/__5_/_-__/_3__/_4__/_6__/8

MOBILE NO.

/__2_/_0__/_2__/__-_/__3_/_2__/_1__/__-_/_4__/_5__/_7__/ 9

OFFICE TEL. NO. /_2__/_0__/__2_/_-__/_4__/_2__/__0_/_-__/_0__/_0__/__3_/ 6

E-MAIL ADDRESS _J_A___C__K__J_A__N__E__1__@__Z__M___A__I_L__._C__O__M________

(*N.B. * This form will become void if the Specimen Signature touches the Border)

Specimen Signature of Applicant

Jane Peters

MARRIED WOMEN PRESENT MARRIAGE DATE OF MARRIAGE

___0__6_/___1_0___/__2_0_1__5_ WASHINGTON DC PLACE OF MARRIAGE _________________________________________

Day Month Year

HUSBAND `S NAME

SURNAME

/_P__/_E__/_T__/_E__/_R__/_S__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

FIRST NAME

/_D__/_E__/_S__/_M__/_O__/_N__/_D__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

NATIONALITY

/_T__/_R__/__I_/_N__/_I__/_D__/_A__/__D_/_I__/_A__/_N__/___/___/___/___/___/___/___/___/___/

PREVIOUS MARRIAGE (S)

Date of Marriage (Date/Month/Year)

24/12/2000

Husband's Name in Full

JOHN DOE

Place of Marriage

BALTIMORE

Husband's Nationality

AMERICAN

3. PERMISSION FROM PARENT / LEGAL GUARDIAN FOR APPLICANTS UNDER 18 YEARS OF AGE

I, FIRST NAME /___N/_/_A_/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

SURNAME

/__N_/_/ _A_/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

Solemnly declare that I am the _______________N__/_A_______________________

(RELATIONSHIP)

of the Applicant, and hereby give permission to

FIRST NAME

/__N_/_/_A_/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

SURNAME

/__N_/_/__A/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

To apply for a Trinidad and Tobago Passport.

Dated

I.D./ Passport # of Parent /Legal Guardian

__________/__________/__________

Day Month

Year

____N___/A________________________

Date of Issue

__________/__________/__________

Day

Month

Year

Signature of Parent/ legal Guardian

4. DECLARATION OF RECOMMENDER * (To be completed by the Recommender Only) *

I, FIRST NAME /___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

SURNAME

/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

Solemnly declare that I am a citizen of Trinidad and Tobago and to the best of my knowledge and belief, all statements made in this application form are true. I make this declaration from my knowledge of the applicant whose name is:

OFFICIAL STAMP OF FIRM / ORGANIZATION

NAME OF APPLICANT

FIRST NAME

/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

SURNAME

/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

Whom I have known personally for ................................................... years and whose photograph I have certified on the reversed side (applicable to renewals only).

MY OCCUPATION /___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

NAME OF FIRM / ORGANIZATION AND ADDRESS

/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

Name of Firm / Organization

/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

Street Name

Town/ City

/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

Town /City

Zip Code

Country

OFFICE TEL. NO. /___/___/___/___/___/___/___/___/___/___/___/ HOME TEL. NO. /___/___/___/___/___/___/___/___/___/___/___/

Dated _______/_________/________ I.D./ D.P. / PASSPORT # _______________________________

Day

Month

Year

Date of Issue _______/_________/________

Day Month

Year

Date of Expiry _______/_________/________

Day Month

Year

Signature of Recommender

5. CITIZEN OF TRINIDAD AND TOBAGO BY:

(A)

BIRTH

[X]

PIN NO.

___9__8_7__6_5__4_3__2_1__0______________________

REGISTRATION DATE

___3__0__/___0__7____/__1_9__7_1__

Day

Month

Year

CERTIFICATE NO. ______B__6__5_4__3_2__1_0________________________ REGISTRATION DISTRICT __S__A__N___F__E_R__N___A__N__D__O_____________

(B)

DESCENT

[ ]

CERTIFICATE NO. ___________________________

(C)

ADOPTION

[ ]

CERTIFICATE NO. ___________________________

(D)

REGISTRATION [ ] / NATURALISATION [ ]

CERTIFICATE NO. __________________________

ISSUE DATE ISSUE DATE ISSUE DATE

_______/_________/__________

Day

Month

Year

_______/_________/__________

Day

Month

Year

_______/_________/__________

Day

Month

Year

ARE YOU NOW OR HAVE YOU EVER BEEN A CITIZEN OF ANY COUNTRY OTHER THAN TRINIDAD AND TOBAGO? YES [X] NO [ ]

If yes, please provide details below

COUNTRY

1. UNITED STATES

2. 3.

CITIZENSHIP BY

NATURALIZATION

CERTIFICATE NO.

76543210

ISSUE DATE (Date/Month/Year)

06/10/2001

6. TRINIDAD AND TOBAGO PASSPORT(S) PREVIOUSLY Have you applied for or been issued any Trinidad and Tobago Passport(s) or other Trinidad and Tobago travel Documents?

If YES, list in the Table provided and submit most recently issued document

PASSPORT NO.

T543210

DATE OF ISSUE (Date/Month/Year)

01/12/1981

YES [ X] NO [ ]

PLACE OF ISSUE

NEW YORK

7. ADDITIONAL REFERENCES

Please provide the following information with respect to two persons who are not relatives and have known you for at least three years.

These persons may be contacted to confirm your identity.

(i) FIRST NAME

/__P_/_E__/_T__/_E__/_R__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

SURNAME

/_R__/_A__/_B__/_B__/__I_/__T_/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

HOME ADDRESS or BUSINESS ADDRESS (IN FULL)

/__5_/__3_/_1__/___/_H__/_I__/_B__/__I_/__S_/_C__/_U__/_S__/___/_D__/_R__/__I_/__V_/_E__/,___/__B_/_A__/_L__/__T_/__I_/_M__/_O__/_R__/_E__/___/___/___/ /_M__/_D__/___/___/__1_/__1_/_3__/_0__/__2_/___/___/___/___/___/___/ TEL. CONTACT /_3__/_0__/__1_/_-__/_4__/_5__/__6_/_-__/_3__/_2__/_4__/5

(ii) FIRST NAME

/_N__/__I_/_C__/_O__/_L__/_E__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

SURNAME

/__F_/_R__/_O__/_S__/_T__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

HOME ADDRESS or BUSINESS ADDRESS (IN FULL)

/_9__/__2_/_1__/___/_T__/__A_/_L__/_B__/_O__/_T__/_T__/___/_L__/_A__/_N__/_E__/,___/_W__/__A_/_S__/_H__/__I_/__N_/_G__/__T_/_O__/_N__/___/_D__/_C__/___/

/__2_/_1__/_4__/__0_/_6__/___/___/___/___/___/___/___/___/___/___/ TEL. CONTACT /_2__/_0__/_2__/_-__/_3__/__4_/_8__/__-_/_6__/_0__/_1__/8

8. DECLARATION OF APPLICANT

I ______J_A__N__E____M__A___R__I_A__P__E__T__E__R__S_________________________________________________ solemnly declare that :

(i) I am a Trinidad and Tobago citizen. (ii) The statements made in this application are true. (iii) The photographs enclosed are a true likeness of me. (iv) I do not have a Trinidad and Tobago Passport other than the one(s) listed at section 6. (v) I know the recommender for at least three years; and (vi) I shall report to the Passport Office or the nearest Trinidad and Tobago Government Office any change in citizenship.

DATED I.D. / PASSPORT # DATE OF ISSUE

____0_6___/___0_8____/___2__0_1__7____

Day

Month

Year

M__D___-_D__L__#__M___-_3_2__1_-_6__5_4__-_9_8_7-001

___2__6___/____0_5___/___2__0_1__6____

Day

Month

Year

Signature

Jane Peters

FOR OFFICIAL USE ONLY

PREQUALIFICATION OFFICER

______________________________________

DATE _______/_________/________

Day

Month

Year

BIRTH CERTIFICATE INFORMATION

COMPUTER GENERATED CERTIFICATE

[ ]

PIN NO._______________________________________

CERTIFICATE NO.____________________________________

REGISTRATION DISTRICT ________________________________________ ENTRY NO._________________________

REGISTRATION DATE _______/_________/________

Day

Month

Year

MANUAL CERTIFICATE

[ ]

CERTIFICATE NO.____________________________________

REGISTRATION DISTRICT ________________________________________

ENTRY NO._________________________

VOL. NO. ___________________

REGISTRATION DATE _______/_________/________

Day

Month

Year

PAGE NO.

___________________

CHAPTER

____________________________________

CITIZENSHIP BY DESCENT CERTIFICATE INFORMATION

CERTIFICATE NO. ____________________________________

CHAPTER

____________________________________

ADOPTION CERTIFICATE INFORMATION

CERTIFICATE NO.____________________________________

ENTRY NO._________________________

BOOK. NO. ________________

SECTION _________________________

ISSUE DATE _______/_________/________

Day

Month

Year

SECTION _________________________

PAGE NO.

___________________

MARRIAGE CERTIFICATE INFORMATION

CERTIFICATE NO.____________________________________

ENTRY NO._________________________

VOL. NO. / BOOK NO.___________

ISSUE DATE _______/_________/________

Day

Month

Year

FOLIO NO. / PAGE NO. ________________

REGISTRATION / NATURALISATION CERTIFICATE INFORMATION

CERTIFICATE NO. ____________________________________

CHAPTER

____________________________________

ISSUE DATE _______/_________/________

Day

Month

Year

SECTION _________________________

SWORN DECLARATION

________________________________________ (NAME OF DECLARANT)

DATED _______/_________/________ REF.

Day

Month

Year

_________

SWORN DECLARATION

________________________________________ (NAME OF DECLARANT)

DATED _______/_________/________ REF.

Day

Month

Year

__________

SWORN DECLARATION

________________________________________ (NAME OF DECLARANT)

DATED _______/_________/________ REF.

Day

Month

Year

__________

DEED POLL NO.

________________________________________

DATED _______/_________/________

Day

Month

Year

DECREE ABSOLUTE

________________________________________

OTHER INFORMATION (Where Necessary)

DATED _______/_________/________

Day

Month

Year

RECEPTION OFFICER DATE

___________________________________________________

_______/_________/________

Day

Month

Year

OFFICER'S STAMP

 ................
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