Form no.
1- ENGLISH
NEW REGULAR PASSPORT APPLICATION (Adult)
THIS FORM IS NOT FOR SALE
DEPARTMENT OF FOREIGN AFFAIRS
Office of Consular Affairs Last Revision: 07 October 2017
INSTRUCTIONS: Please PRINT entries legibly using black or blue ink only. Supply
the necessary informa on and indicate “N/A” for entries with no answers.
Check boxes as appropriate.
CAPTURE SITE PRE-PROCESSING (Do not write on this part)
APPOINTMENT VERIFICATION: REMARKS:
PASSPORT APPLICANT'S INFORMATION
1. LAST NAME YOSHINAGA
2. FIRST NAME SHARIAH ICHE-IRIKA
3. MIDDLE NAME OR MAIDEN LAST NAME NUÑEZ
4. GENDER 5. DATE OF BIRTH (EX. 01 JAN 2017) 6. PLACE OF BIRTH
MALE 23-FEB-1999 GEN SANTOS CITY
FEMALE
7. CIVIL 8A. HOW DID YOU ACQUIRE PHL 8B. DID YOU EVER LOSE YOUR PH
STATUS CITIZENSHIP? CITIZENSHIP? YES NO
SINGLE BY BIRTH 8C. ARE YOU CURRENTLY A CITIZEN OF
MARRIED BY NATURALIZATION ANOTHER COUNTRY? YES NO
BY RE-ACQUISITION(RA NO. 9225) 8D. IF YES, FROM WHAT COUNTRY?
WIDOW/ER BY ELECTION 8E. HAVE YOU SERVED IN ANY FOREIGN
ANNULLED BY LEGISLATION MILITARY? YES NO
DIVORCED BY MARRIAGE 8D. IF YES, WHAT COUNTRY?
APPLICANT'S CONTACT INFORMATION
9A. ADDRESS ABROAD
9B. ADDRESS IN THE PHILIPPINES
B11 B1C2 PUROK SANTO NIÑO BARANGAY CALUMPANG, GENERAL SANTOS CITY 9500,
PHILIPPINES
10. TELEPHONE/MOBILE NUMBER 09662294970
11. EMAIL ADDRESS irikinaga@gmail.com
12. APPLICANT'S SPOUSE'S NAME: ,
13A. PERSON TO CONTACT IN CASE OF EMERGENCY: BARRERA, BLITZ VARSI MIRANDA
13B. TEL/MOBILE NO.: +16192457527
PARENTAL INFORMATION
14. FATHER'S DETAILS 15. MOTHER'S DETAILS
LAST NAME: YOSHINAGA LAST NAME: NUÑEZ
FIRST NAME: KAZUO FIRST NAME: VICTORIA
MIDDLE NAME: MIDDLE NAME: SEPUESCA
CITIZENSHIP: (at time of applicant's birth) CITIZENSHIP: (at time of applicant's birth)
JAPAN PHILIPPINES
DECLARATION OF APPLICANT
I HEREBY DECLARE AND AFFIRM that 1) I am a Filipino citizen. 2) The information provided in
this application is true and correct. 3) The supporting documents attached are authentic. 4)
I consent to the verification by the Philippine Government of the information I provided to
establish my personal particulars, and further consent to its use for any lawful purpose. 5)
I am aware that the information provided in this application will be treated in accordance
with relevant privacy regulations. 6) I am aware that under the law, I am allowed to hold
only one valid regular Philippine passport at a given time. 7) I am aware that making false
statements in this passport application and furnishing falsified or forged documents are
punishable by fine or imprisonment, and grounds for suspension or denial of application. 8) I
understand and accept that the release of the passport could be subject to delay due to
unforeseen events beyond the control of the Department of Foreign Affairs.
17. SIGNATURE OVER PRINTED NAME 18. DATE (EX. 01 JAN 2017)
DO NOT WRITE BELOW THIS LINE. FOR THE DEPARTMENT’S USE ONLY.
PROOF OF PHL CITIZENSHIP IDENTITY DOCUMENT SUPPORTING DOCUMENTS
BIRTH CERTIFICATE FROM PHL SUBMITTED MARRIAGE CERTIFICATE FROM
STATISTICS AUTHORITY COMELEC VOTER'S ID PHL STATISTICS AUTHORITY
CERTIFICATE OF LTO DRIVER'S LICENSE VOTER'S REGISTRATION
NATURALIZATION PROFESSIONAL REGULATORY RECORD
IDENTIFICATION CERTIFICATE COMMISSION ID COURT ORDER
OF CITIZENSHIP UNIFIED MULTIPURPOSE ID NBI CLEARANCE
ELECTION OF PHL CITIZENSHIP (UMID) OTHERS:
OTHERS: PWD ID
GSIS / SSS ID
SENIOR CITIZEN'S ID
OTHERS:
REMARKS: PASSPORT WATCHLIST VERIFICATION:
PROCESSOR'S SIGNATURE: ENCODER'S SIGNATURE:
OFFICIAL RECEIPT/PAYMENT SLIP NO.: DATE OF TRANSACTION:
