PASSPORT APPLICATION

FSM PASSPORT APPLICATION FORM

FSM FORM 5001B-REVISED FORM 5001A

Applicant must complete this form and forward it to the
Division of Immigration & Labor, Department of Justice,
FSM National Government, Palikir, Pohnpei FM 96941

PLEASE FOLLOW INSTRUCTIONS
Type of Passport: [ ] Ordinary [ ] Official [ ] Diplomatic

FOR OFFICIAL USE ONLY

Document Issued On:______________
Issuing Official:______________

Applicant Photo
1 3/16 x 1 ¾

FSM PASSPORT APPLICATION FORM
Type of Passport:
Ordinary
Official
Diplomatic
Applicant Photo
Name:



Other Names You Have Used:

Date of Birth:

Gender:
Miss
Mrs.
Ms.
Mr.
Height:


Hair Color:

Eye Color:

Birth Place:

Home Address:

Current Postal Address:

Email Address:

Phone Number:

Have you ever been issued a foreign passport or FSM passport?
Yes
No
Basis of FSM citizen:
Birth
Naturalization
Other means (Provide proof)
Father Information:





Is your father FSM citizen?
Yes
No
Mother Information:





Is your mother FSM citizen?
Yes
No
Signature of Applicant Required:

Please sign within the box. Signature must not touch box border lines.

Signature of parent or guardian if applicant is under age 14 or unable to sign application:

Subscribed and sworn to before me this ______ day of ___________ 20___

Certification:

I hereby certify that I have reviewed the application and found to be complete and I am satisfied that the applicant is a citizen of the Federated States of Micronesia, and that he/she does not owe allegiance to any foreign country.