This form contains 86 fields organized into 12 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Address Information
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Enter your permanent street address.
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Enter your permanent apartment or unit number.
City Text
Enter the city of your permanent address.
Permanent Address State Text
Enter the state of your permanent address.
Zip Code Text
Enter the zip code of your permanent address.
Contact Information
Email Text
Enter your email address.
App Phone 1 Text
Enter the first three digits of your phone number.
Max length: 3 characters
App Phone 2 Text
Enter the next three digits of your phone number.
Max length: 3 characters
App Phone 3 Text
Enter the last four digits of your phone number.
Max length: 4 characters
Additional Contact Phone Numbers Text
Enter additional contact phone numbers.
Additional # 1_Home CheckBox
Check this box if the additional contact number is a home number.
Additional # 1_Cell CheckBox
Check this box if the additional contact number is a cell number.
Additional Contact Phone Numbers 2 Text
Enter another additional contact phone number.
Additional # 2_Home CheckBox
Check this box if the second additional contact number is a home number.
Additional # 2 CheckBox
Check this box if the second additional contact number is another type of number.
Additional # 1_Work CheckBox
Check this box if the first additional contact number is a work number.
Additional # 1_Other CheckBox
Check this box if the first additional contact number is another type of number.
Additional # 2_Work CheckBox
Check this box if the second additional contact number is a work number.
Additional # 2_Other CheckBox
Check this box if the second additional contact number is another type of number.
Eligibility
Yes CheckBox
Check this box to answer 'Yes' to the corresponding question.
Eligibility Criteria
Most Recent_YES RadioButton
Select 'Yes' if your most recent U.S. passport book and/or card was issued within the last 15 years.
Most Recent_NO RadioButton
Select 'No' if your most recent U.S. passport book and/or card was not issued within the last 15 years.
16 Years_YES RadioButton
Select 'Yes' if you were at least 16 years old when your most recent U.S. passport book and/or card was issued.
16 Years_NO_2 RadioButton
Select 'No' if you were not at least 16 years old when your most recent U.S. passport book and/or card was issued.
Less Than 15_YES RadioButton
Select 'Yes' if your most recent U.S. passport book and/or card was issued less than 15 years ago.
Less Than 15_NO RadioButton
Select 'No' if your most recent U.S. passport book and/or card was issued more than 15 years ago.
Damaged_YES RadioButton
Select 'Yes' if your most recent U.S. passport book and/or card is damaged.
Damaged_NO RadioButton
Select 'No' if your most recent U.S. passport book and/or card is not damaged.
Not Limited_YES RadioButton
Select 'Yes' if your most recent U.S. passport book and/or card was not limited in validity.
Not Limited_NO RadioButton
Select 'No' if your most recent U.S. passport book and/or card was limited in validity.
Name Changed_YES RadioButton
Select 'Yes' if your name has changed since your most recent U.S. passport book and/or card was issued.
Name Changed_NO RadioButton
Select 'No' if your name has not changed since your most recent U.S. passport book and/or card was issued.
Emergency Contact Information
Emergency Contact Name Text
Enter the name of your emergency contact.
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Enter the address of your emergency contact.
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Enter the apartment or unit number of your emergency contact.
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Enter the city of your emergency contact.
Emerg State Text
Enter the state of your emergency contact.
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Enter the zip code of your emergency contact.
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Enter the phone number of your emergency contact.
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Specify your relationship to the emergency contact (e.g., spouse, parent, friend).
Form Actions
Clear Button
Click this button to clear the form.
Mailing Address
Mailing Address Line 1: Street/RFD#, P.O. Box, or URB Text
Enter the first line of your mailing address, including street, P.O. Box, or URB.
Max length: 36 characters
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Enter the second line of your mailing address, if applicable.
Max length: 36 characters
City Text
Enter the city of your mailing address.
Max length: 11 characters
App Mailing Address State Text
Enter the state of your mailing address using the two-letter state abbreviation.
Max length: 2 characters
Zip Code Text
Enter the ZIP code of your mailing address.
Max length: 6 characters
City Text
Enter the country of your mailing address.
Max length: 11 characters
Name Change Information
Changed by Marriage CheckBox
Check this box if your name has changed due to marriage.
Changed by Court Order CheckBox
Check this box if your name has changed due to a court order.
Name Change Place Text
Enter the place where your name change occurred.
Name Change Date (mm/dd/yyyy) Text
Enter the date when your name change occurred in the format mm/dd/yyyy.
Passport Information
Your name as printed on your most recent U.S. passport book and/or passport card Text
Enter your name as it appears on your most recent U.S. passport book and/or passport card.
Max length: 25 characters
Most recent U.S. passport book number Text
Enter the number of your most recent U.S. passport book.
Max length: 17 characters
Book Issue Date mm/dd/yyyy Text
Enter the issue date of your most recent U.S. passport book in mm/dd/yyyy format.
Max length: 8 characters
Most recent U.S. passport card number Text
Enter the number of your most recent U.S. passport card.
Max length: 17 characters
Card Issue Date mm/dd/yyyy Text
Enter the issue date of your most recent U.S. passport card in mm/dd/yyyy format.
Max length: 8 characters
Passport Selection
Selection_Book CheckBox
Check this box if you are applying for a U.S. passport book.
Selection CheckBox
Check this box if you are applying for a U.S. passport card.
Selection_Both CheckBox
Check this box if you are applying for both a U.S. passport book and card.
Regular or Large Book_Regular CheckBox
Check this box if you are applying for a regular-sized U.S. passport book.
Regular or Large Book_Large CheckBox
Check this box if you are applying for a large-sized U.S. passport book.
Personal Information
Name Last Text
Enter your last name as it appears on your most recent U.S. passport book and/or card.
Max length: 21 characters
First Text
Enter your first name as it appears on your most recent U.S. passport book and/or card.
Max length: 17 characters
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Enter your middle name as it appears on your most recent U.S. passport book and/or card.
Max length: 16 characters
App DOB MM Text
Enter the month of your date of birth (MM).
Max length: 2 characters
App DOB DD Text
Enter the day of your date of birth (DD).
Max length: 2 characters
App DOB YYYY Text
Enter the year of your date of birth (YYYY).
Max length: 4 characters
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Enter the place of your birth (city and state or country).
Max length: 17 characters
Gender_M CheckBox
Check this box if your gender is male.
Gender_F CheckBox
Check this box if your gender is female.
Gender_X CheckBox
Check this box if your gender is non-binary or unspecified.
App SSN 1 Text
Enter the first three digits of your Social Security Number.
Max length: 3 characters
App SSN 2 Text
Enter the middle two digits of your Social Security Number.
Max length: 2 characters
App SSN 3 Text
Enter the last four digits of your Social Security Number.
Max length: 4 characters
App List all other name you have used Text
List any other names you have used.
Max length: 17 characters
App List all other names you have used 2 Text
List any additional names you have used.
Max length: 17 characters
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Enter your full name (Last, First, Middle).
Date of Birth 2 Text
Enter your date of birth.
Height Text
Enter your height.
Hair Color Text
Enter your hair color.
Eye Color Text
Enter your eye color.
Occupation Text
Enter your occupation.
Employer or School Text
Enter the name of your employer or school.
Travel Information
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Enter the date you plan to depart for your travel.
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Enter the date you plan to return from your travel.
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List the countries you plan to visit during your travel.